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ARTICLE TITLE: Nutrition and Physical Activity Guidelines for Cancer Survivors
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EDUCATIONAL OBJECTIVES:
After reading the article Nutrition and Physical Activity Guidelines for Cancer Survivors, the learner should be able to provide advice to patients regarding current
evidence relevant to the impact of nutrition and physical activity choices on:
1. Symptom management in patients undergoing cancer therapy.
2. Cancer recurrence, survival, and risk of other chronic diseases (including second primary cancers) after the treatment of cancer.
ACTIVITY DISCLOSURES
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ACS CONTINUING PROFESSIONAL EDUCATION COMMITTEE DISCLOSURES
Editor-in-Chief and ACS Chief Medical Ofcer

Otis Brawley, MD, serves as an unpaid medical consultant to GlaxoSmithKline and Sano-Aventis. Dr. Brawley reports no other nancial relationships or interests.
Editor, Director of Continuing Professional Education, and ACS Director of Medical Content
Ted Gansler, MD, MBA, MPH, has no nancial relationships or interests to disclose.
Nursing CE Nurse Planner and Associate Editor
Marcia Grant, RN, DNSc, FAAN, has no nancial relationships or interests to disclose.
AAFP Family Physician representative and Associate Editor
Richard Wender, MD, has no nancial relationships or interests to disclose.
AUTHOR DISCLOSURES
Cheryl L. Rock, PhD, RD; Colleen Doyle, MS, RD; Wendy Demark-Wahnefried, PhD, RD; Jeffrey Meyerhardt, MD, MPH; Kerry S. Courneya, PhD;
Anna L. Schwartz, FNP, PhD, FAAN; Elisa V. Bandera, MD, PhD; Kathryn K. Hamilton, MA, RD, CSO, CDN; Barbara Grant, MS, RD, CSO, LD;
Marji McCullough, ScD, RD; Tim Byers, MD, MPH; Ted Gansler, MD, MBA, MPH, have no conicts of interest to disclose.
This activity has been reviewed and revised on the basis of feedback provided by the American Cancer Society 2011 Nutrition, Physical Activity and
Cancer Survivorship Advisory Committee. The committee had no conicts of interest to disclose.
Conicts of interest have been identied and resolved in accordance with Blackwell Futura Media Services Policy on Activity Disclosure and Conict of Interest.
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CA: A Cancer Journal for Clinicians
SPONSORED BY THE AMERICAN CANCER SOCIETY, INC.
CA CANCER J CLIN 2012;62:242-274
Nutrition and Physical Activity Guidelines

for Cancer Survivors
Cheryl L. Rock, PhD, RD1; Colleen Doyle, MS, RD2; Wendy Demark-Wahnefried, PhD, RD3; Jeffrey Meyerhardt, MD, MPH4;
Kerry S. Courneya, PhD5; Anna L. Schwartz, FNP, PhD, FAAN6; Elisa V. Bandera, MD, PhD7;
Kathryn K. Hamilton, MA, RD, CSO, CDN8; Barbara Grant, MS, RD, CSO, LD9;
Marji McCullough, ScD, RD10; Tim Byers, MD, MPH11; Ted Gansler, MD, MBA, MPH12
Cancer survivors are often highly motivated to seek information about food choices, physical activity, and dietary supplements to
improve their treatment outcomes, quality of life, and overall survival. To address these concerns, the American Cancer Society
(ACS) convened a group of experts in nutrition, physical activity, and cancer survivorship to evaluate the scientific evidence and
best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer. This report summarizes their
findings and is intended to present health care providers with the best possible information with which to help cancer survivors
and their families make informed choices related to nutrition and physical activity. The report discusses nutrition and physical activity guidelines during the continuum of cancer care, briefly highlighting important issues during cancer treatment and for patients
with advanced cancer, but focusing largely on the needs of the population of individuals who are disease free or who have stable
disease following their recovery from treatment. It also discusses select nutrition and physical activity issues such as body weight,
food choices, food safety, and dietary supplements; issues related to selected cancer sites; and common questions about diet,
physical activity, and cancer survivorship. CA Cancer J Clin 2012;62:242-274. VC 2012 American Cancer Society.
To earn free CME credit or nursing contact hours for successfully completing the online quiz based on this article, go to
acsjournals.com/ce.
Introduction
A cancer survivor is defined as anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of
their life.1 Given advances in early detection and treatment, the number of US cancer survivors is estimated to exceed 12
million and is growing steadily, so that approximately one in every 25 Americans is now a cancer survivor.1,2 Many cancer
survivors are highly motivated to seek information about food choices, physical activity, dietary supplement use, and
complementary nutritional therapies to improve their response to treatment, speed recovery, reduce their risk of recurrence,
and improve their quality of life.3
The trajectory of cancer survivorship is marked by 3 general phases: 1) active treatment and recovery; 2) living after
recovery, including survivors who are disease free or who have stable disease; and 3) advanced cancer and end of life.
Approximately 68% of Americans diagnosed with cancer now live more than 5 years,4 and their nutritional needs change
over the course of survivorship. The need for informed lifestyle choices for cancer survivors becomes particularly important
as they look forward to the successful completion of therapy and seek self-care strategies to improve their long-term outcomes. For many long-term cancer survivors, healthy weight management, a healthful diet, and a physically active lifestyle
aimed at preventing recurrence, second primary cancers, and other chronic diseases should be a priority. For other survivors,
regaining health following a difficult treatment or managing nutritional needs and activity levels while living with advanced
cancer becomes a particular challenge.
1
Professor, Department of Family and Preventive Medicine, School of Medicine, University of California, San Diego, La Jolla, CA; 2Director, Nutrition and
Physical Activity, Cancer Control Science, American Cancer Society, Atlanta, GA; 3Professor and Webb Endowed Chair of Nutrition Sciences, University of
Alabama at Birmingham, Birmingham, AL; 4Associate Professor of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; 5Professor
and Canada Research Chair in Physical Activity and Cancer, University of Alberta, Edmonton, Alberta, Canada; 6Affiliate Professor, University of Washington,
Seattle, WA, Associate Professor, Idaho State University, Pocatello, ID; 7Associate Professor, Department of Epidemiology, The Cancer Institute of New
Jersey, New Brunswick, NJ; 8Outpatient Oncology Dietitian, Carol G. Simon Cancer Center, Morristown Memorial Hospital, Morristown, NJ; 9Oncology
Nutritionist, Saint Alphonsus Regional Medical Center Cancer Care Center, Boise, ID; 10Nutritional Epidemiologist, Epidemiology and Surveillance Research,
American Cancer Society, Atlanta, GA; 11Associate Dean for Public Health Practice, Colorado School of Public Health, Associate Director for Cancer
Prevention and Control, University of Colorado Cancer Center, Aurora, CO; 12Director, Medical Content, American Cancer Society, Atlanta, GA.
Corresponding author: Colleen Doyle, MS, RD, American Cancer Society, 250 Williams St NW, Suite 600, Atlanta, GA 30303; colleen.doyle@cancer.org
DISCLOSURES: The authors report no conflicts of interest.
C
V
2012 American Cancer Society, Inc. doi:10.3322/caac.21142. Available online at cacancerjournal.com

VOLUME 62 _ NUMBER 4 _ JULY/AUGUST 2012
243
Nutrition and Physical Activity Guidelines for Cancer Survivors
After receiving a diagnosis of cancer, survivors soon find

there are few clear answers to even the simplest questions,
such as: Should I change what I eat? Should I exercise more?
Should I gain or lose weight? Should I take dietary supplements? Cancer survivors receive a wide range of advice from
many sources about foods they should eat, foods they
should avoid, how they should exercise, and what types of
supplements they should take, if any. Unfortunately, this
advice is often inconsistent and not supported by data.
Overview of the Report

The American Cancer Society (ACS) convened a group of
experts in nutrition, physical activity, and cancer to evaluate
and synthesize the scientific evidence and best clinical
practices related to nutrition and physical activity after the
diagnosis of cancer. This report summarizes their findings
and updates the most recent report published in 2006.5
Although this report is intended for health care providers
caring for cancer survivors, it can also be used directly by
highly motivated survivors and their families. The ACS
also provides shorter and simpler summaries of the recommendations in this report, which are written specifically for
survivors and caregivers. New scientific evidence has
emerged since 2006 on the relationship between nutrition,
physical activity, and issues of quality of life, comorbid
conditions, cancer recurrence, the development of second
primary cancers, and overall survival. Although this
evidence is incomplete, reasonable conclusions and recommendations can be made on several issues that can guide
choices about body weight, foods, physical activity, and
dietary supplement use.
This report presents information in 4 sections. The first
section addresses nutrition and physical activity across the
phases of cancer survivorship; the second section addresses
the guidelines for cancer survivors in specific areas of weight
management, physical activity, food choices, alcohol intake,
and food safety; the third section provides information
regarding selected cancer sites; and the fourth section
includes answers to common questions many survivors have.
It is important that health care providers, cancer survivors,
and caregivers consider the nutritional and physical activity
issues discussed in this report within the context of the individual survivors overall medical and health situation. This
report is not intended to imply that nutrition and physical
activity are more important than other clinical or self-care
approaches. For example, although we present dietary
suggestions for persons with bowel changes and fatigue, we
recognize that other medical interventions may be more
effective in controlling those symptoms. Furthermore, just as
standard treatment options vary by the type of cancer, nutrition and physical activity factors may impact some cancer
types but not others. In writing these recommendations, we
have assumed that survivors and their caregivers are receiving
244
appropriate medical and supportive care and are seeking

high-quality information on self-care strategies to provide
further relief of symptoms and to enhance health.
Physicians and other health care providers have a unique
opportunity to guide cancer patients toward optimal
lifestyle choices, and thus can favorably influence the survivorship trajectory regardless of the individuals survivorship
phase. The power of physician advice in facilitating preventive health behaviors has been consistently demonstrated. A
study of 450 breast cancer survivors6 showed that a simple
recommendation from the oncologist to exercise resulted in
significant increases in physical activity. This is not to say
that the physician needs to provide in-depth counseling to
patients, but rather to at least plant an appropriate message
and then either refer patients to registered dietitians or
exercise trainers who are certified within the area of cancer
supportive care, or to provide user-friendly self-help
brochures or other resources to support lifestyle changes.
Nutrition and Physical Activity Across the

Continuum of Cancer Survivorship
The continuum of cancer survivorship includes treatment
and recovery; long-term disease-free living or living with
stable disease; and, for some, living with advanced cancer.
Survivors in each of these phases have different needs and
challenges with respect to nutrition and physical activity.
Nutrition During Cancer Treatment and Recovery

Prior to the identification of effective cancer screening and
treatment, many people were diagnosed with cancer in a
late stage, when they may have already experienced the
weight loss and cachexia that was common among patients
with late-stage cancer. In addition, patients undergoing
cancer treatment often experienced significant untreated
nausea and vomiting, which led to further weight loss.
Because of these clinical experiences, cancer was considered
to be a disease associated with weight loss, rather than
obesity. However, many patients now being diagnosed have
early stage disease and treatments are more effective.
Therefore, with growing numbers of patients beginning the
cancer treatment process already overweight or obese,7
additional weight gain is a frequent complication of
treatment.8 While highly variable depending on the type of
cancer and stage at diagnosis, cancer can cause profound
metabolic and physiological alterations that can affect the
nutrient requirements for macro- and micronutrients.9
Symptoms such as anorexia, early satiety, changes in taste
and smell, and disturbances of the bowel are common side
effects of cancer and cancer treatment and can lead to
inadequate nutrient intake and subsequent malnutrition.
Substantial weight loss and poor nutritional status can still
occur early in the course of some cancers, although the
TABLE 1. Suggestions for Locating Specialized Nutrition Counseling

l
l
Survivors should ask their health care provider for a referral to see an RD, preferably an RD who is also a CSO, if they experience nutrition-related challenges.
If an oncology dietitian is not available in the medical or surgical practice or medical center where they receive their cancer treatment and care, an
appointment with a dietitian associated with their primary care provider clinic may be arranged.
Survivors, caregivers, and providers can also consult the Academy of Nutrition and Dietetics to identify a private practice dietitian in their area.
RD indicates registered dietitian; CSO certified specialist in oncology.
prevalence of malnutrition and weight loss varies widely

across cancer types and stage at diagnosis.10 Consuming
enough calories to prevent additional weight loss is therefore
vital for survivors at risk of unintentional weight loss, such as
those who are already malnourished or those who receive
anticancer treatments affecting the gastrointestinal tract.10,11
All of the major modalities of cancer treatment, including surgery, radiation, and chemotherapy, can significantly
affect nutritional needs; alter regular eating habits; and
adversely affect how the body digests, absorbs, and uses
food.9,12 Nutritional assessment for survivors should therefore begin as soon after diagnosis as possible and should
take into consideration treatment goals (curative, control,
or palliation) while focusing on both the current nutritional
status and anticipated nutrition-related symptoms.12
During active cancer treatment, the overall goals of
nutritional care for survivors should be to prevent or resolve
nutrient deficiencies, achieve or maintain a healthy weight,
preserve lean body mass, minimize nutrition-related side
effects, and maximize quality of life. Studies confirm the
benefit of dietary counseling during cancer treatment for
improving outcomes, such as fewer treatment-related
symptoms, improved quality of life, and improved dietary
intake.13-16 Suggestions for finding an oncology nutrition
expert to provide dietary counseling are provided in Table 1.
Providing individualized nutritional advice can improve
dietary intake and potentially decrease some of the
toxicities associated with cancer treatments.9 Examples of
situations that may benefit from seeking individualized
advice include the following:
For survivors experiencing anorexia or early satiety, and
who are at risk of becoming underweight, consuming
smaller, more frequent meals with minimal liquids consumed during meals can help to increase food intake.
Liquids can and should be consumed in between meals
to avoid dehydration.
For survivors who cannot meet their nutritional needs
through foods alone, fortified, commercially prepared or
homemade nutrient-dense beverages or foods can improve
the intake of energy and nutrients.
For survivors who are unable to meet their nutritional
needs through these measures and who are at risk of
becoming malnourished, other means of nutritional
support may be needed, such as pharmacotherapy using

appetite stimulants, enteral nutrition via tube feeding,
or intravenous parenteral nutrition.
The use of vitamins, minerals, and other dietary
supplements during cancer treatment remains controversial.
For example, it may be counterproductive for survivors to
take folate supplements or to eat fortified food products
that contain high levels of folate when receiving antifolate
therapies such as methotrexate.9 Many dietary supplements
contain levels that exceed the amount normally found in
food and recommended in the Dietary Reference Intakes
for optimal health.17-21 Because of emerging evidence on
detrimental effects from even the modest use of dietary
supplements in the oncology population, many cancer
experts continue to advise against taking supplements
during and after treatment, or suggest limiting use to those
dietary supplements needed to treat a deficiency or promote
another aspect of health. One reason for concern involves
the theory that a subgroup of dietary supplements,
antioxidants, could prevent the cellular oxidative damage to
cancer cells that is required for treatments such as radiation
therapy and chemotherapy to be effective.22 In contrast,
some clinicians have noted that the possible harm from
antioxidants is only hypothetical and that there may be a
net benefit to helping protect normal cells from the
collateral damage associated with these therapies.23,24
With compelling evidence against the use of select
supplements in certain oncology populations, health care
professionals and survivors need to proceed with caution.25
If interested in supplementation, individuals should first
assess whether they are nutrient deficient, avoid ingesting
supplements that exceed more than 100% of the Daily
Value, and consider limiting dietary supplement use to
therapeutic interventions for chronic conditions such as
osteoporosis and macular degeneration, for which scientific
evidence supports the likelihood of benefits and low risk of
harm.
Exercise During Cancer Treatment

An increasing number of studies have examined the
therapeutic value of exercise during primary cancer treatment.26,27 Existing evidence strongly suggests that exercise
245
is not only safe and feasible during cancer treatment, but

that it can also improve physical functioning, fatigue, and
multiple aspects of quality of life.28 Some studies have also
suggested that physical activity may even increase the rate
of completion of chemotherapy.29 Current evidence is
unclear on the interaction of exercise and chemotherapy
efficacy, but in at least one randomized controlled exercise
study, there was no evidence of a negative exercise effect on
response to chemotherapy in a cohort of lymphoma survivors.30 One animal study also reported that exercise did not
interfere with the efficacy of chemotherapy.31
The decision regarding when to initiate and how to
maintain physical activity should be individualized to the
patients condition and personal preferences. Exercise
during cancer treatment improves multiple posttreatment
adverse effects on bone health, muscle strength, and other
quality-of-life measures.32-36 Persons receiving chemotherapy and/or radiation therapy who are already on an exercise
program may need to exercise at a lower intensity and/or
for a shorter duration during their treatment, but the
principal goal should be to maintain activity as much as
possible. Some clinicians advise certain survivors to wait to
determine their extent of side effects with chemotherapy
before beginning an exercise program. For those who
were sedentary before diagnosis, low-intensity activities
such as stretching and brief, slow walks should be adopted
and slowly advanced. For older individuals and those
with bone metastases or osteoporosis, or significant impairments such as arthritis or peripheral neuropathy, careful
attention should be given to balance and safety to reduce
the risk of falls and injuries. The presence of a caregiver
or exercise professional during exercise sessions can be
helpful. If the disease or treatment necessitates periods of
bed rest, then reduced fitness and strength, as well as loss
of lean body mass, can be expected. Physical therapy
during bed rest is therefore advisable to maintain strength
and range of motion and can help to counteract fatigue
and depression.
Recovery Immediately After Treatment

After cancer therapy has been completed, the next phase of
cancer survivorship is recovery. In this phase, many symptoms and side effects of treatment that have affected nutritional and physical well-being begin to resolve. Typically,
survivors recover from the acute effects of their specific
treatment within weeks or months after completing
therapy, although in some instances, side effects of treatment persist. In addition, late-occurring or latent effects of
treatment may appear long (months or years) after treatment has been completed.37-39 Examples of continuing side
effects or complications of cancer treatment relevant to
nutritional status include persistent fatigue, peripheral
246
TABLE 2. American Cancer Society Guidelines on Nutrition and

Physical Activity for Cancer Survivors
Achieve and maintain a healthy weight.
l If overweight or obese, limit consumption of high-calorie foods and
beverages and increase physical activity to promote weight loss.
Engage in regular physical activity.
Avoid inactivity and return to normal daily activities as soon as possible
following diagnosis.
l Aim to exercise at least 150 minutes per week.
l Include strength training exercises at least 2 days per week.
l
Achieve a dietary pattern that is high in vegetables, fruits, and whole grains.
l Follow the American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Prevention.
neuropathy, changed sense of taste, difficulty chewing and

swallowing, difficulty in replenishing lean body mass after
the completion of therapy, and persistent bowel changes
such as diarrhea or constipation.
Survivors may require ongoing nutritional assessment
and guidance in this phase of survival.40-42 For those who
emerge from treatment underweight or with compromised
nutritional status, continued supportive care, including
nutritional counseling and pharmacotherapy to relieve
symptoms and stimulate appetite, is helpful in the recovery
process.13,43 After treatment, a program of regular physical
activity is essential to aid in the process of recovery and
improve fitness.
Long-Term Disease-Free Living or Stable Disease

During this phase, setting and achieving lifelong goals
for weight management, a physically active lifestyle, and
a healthy diet are important to promote overall health,
quality of life, and longevity.44 While cancer survivorship
is a relatively new area of study and much needs to be
learned regarding the optimal diet and physical activity
practices for cancer survivors, current evidence supports
recommendations in 3 basic areas: weight management,
physical activity, and dietary patterns. These guidelines
are featured in Table 2. Because individuals who have
been diagnosed with cancer are at a significantly higher
risk of developing second primary cancers,45 and may
also be at an increased risk of chronic diseases such as
cardiovascular disease, diabetes, and osteoporosis, the
guidelines established to prevent those diseases are especially
important for cancer survivors.46-51 Because family members of cancer survivors may also be at a higher risk of
developing cancer, they should also be encouraged to
follow the ACS nutrition and physical activity guidelines
for cancer prevention.52
Convincing data exist that obesity is associated with an
increased risk of breast cancer recurrence,53,54 and similar
evidence on obesity and prognosis is also accumulating for
other cancers.55-57 On the opposite end of the spectrum,
those with aerodigestive tumors such as head and neck,

esophagus, or lung cancers may be malnourished and
underweight at the point of diagnosis, and could therefore
benefit from increasing their body weight.58-61 Therefore,
achieving and maintaining a healthy weight, as well as
consuming a nutrient-rich diet and maintaining a physically
active lifestyle, are important to improve long-term health
and well-being.
Extensive research has been conducted on the benefits of
physical activity during recovery from cancer-related treatments, and an increasing number of studies have examined
the impact of physical activity on cancer recurrence and
long-term survival.28 Exercise has been shown to improve
cardiovascular fitness, muscle strength, body composition,
fatigue, anxiety, depression, self-esteem, happiness, and
several components of quality of life (physical, functional,
and emotional) in cancer survivors. In addition, exercise
studies have targeted certain symptoms particular to specific
cancers and the adverse effects of specific therapies
(eg, lymphedema in survivors of breast cancer) and shown
beneficial effects that are more cancer-specific. At least 20
prospective observational studies have shown that physically active cancer survivors have a lower risk of cancer
recurrences and improved survival compared with those
who are inactive, although studies remain limited to breast,
colorectal, prostate, and ovarian cancer, and randomized
clinical trials are still needed to better define the impact of
exercise on such outcomes.62-65
Living With Advanced Cancer

For individuals living with advanced cancer, a healthy diet
and some physical activity may be important factors in
establishing and maintaining a sense of well-being and
enhancing their quality of life. Although advanced cancer is
sometimes accompanied by substantial weight loss, it is not
inevitable that individuals with cancer lose weight or
experience malnutrition.9 Many patients with advanced
cancer need to adapt their food choices and meal patterns to
meet nutritional needs and to manage cancer symptoms or
treatment side effects such as fatigue, bowel changes, and a
diminished sense of taste or appetite. For persons experiencing anorexia, negative changes in weight, or difficulty in gaining weight, convincing evidence exists that some medications
(eg, megestrol acetate) can help to enhance appetite.66
Additional nutritional supplementation such as nutrient-dense
beverages and foods can be consumed by those who cannot
eat or drink enough to maintain sufficient energy intake.
The use of enteral nutrition and parenteral nutrition support should be individualized with recognition of overall
treatment goals (control or palliation) and the associated
risks of medical complications and/or ethical dilemmas.
Both the American Society for Parenteral and Enteral
Nutrition67 and the Academy of Nutrition and Dietetics

position papers recommend that nutrition support be used
selectively and with clear purpose.68,69
Several systematic reviews have suggested that some level
of physical activity is feasible and may improve quality of life
and physical function in persons with advanced cancer,
although this is likely specific to certain cancer types.70,71
Thus, the evidence of a benefit from exercise for survivors of
advanced cancer is insufficient to make general recommendations. Recommendations for nutrition and physical activity
in those who are living with advanced cancer are best based
on individual nutrition needs and physical abilities.
Selected Issues in Nutrition and Physical

Activity for Cancer Survivors
Body Weight
In the United States, obesity is a problem of epidemic
proportions72 and is a well-established risk factor for some
of the most common cancers.52 Overweight and obesity are
clearly associated with an increased risk of developing many
cancers, including cancers of the breast in postmenopausal
women73; colon and rectum74; endometrium; and adenocarcinoma of the esophagus, kidney, and pancreas.47,75
Obesity is also probably associated with an increased risk of
cancer of the gallbladder,47 and may also be associated with
an increased risk of cancers of the liver, cervix, and ovary, as
well as non-Hodgkin lymphoma, multiple myeloma, and
aggressive forms of prostate cancer.52 Thus, many cancer
survivors are overweight or obese at the time of diagnosis.
Increasing evidence indicates that being overweight
increases the risk of recurrence and reduces the likelihood
of disease-free and overall survival among those diagnosed
with cancer.53,54,63,76-89 Such data suggest that the avoidance of weight gain and weight maintenance throughout
treatment may be important for survivors who are normal
weight, overweight, or obese at the time of diagnosis, and
that intentional weight loss following treatment recovery
among those who are overweight and obese may be associated
with health-related benefits.90
Although currently there is limited evidence to support
the hypothesis that intentional weight loss posttreatment in
cancer survivors will result in improved prognosis and
overall survival,53 results of the Womens Intervention
Nutrition Study (WINS) found that a low-fat diet that
resulted in a 6-pound weight loss (approximately 4% of
initial weight) reduced the risk of recurrence among postmenopausal breast cancer survivors (especially those with
estrogen receptor [ER]-negative tumors).91 However, this
trial was not designed to specifically address weight loss,
and the results are confounded by the impact of a low-fat
diet that was the focus of the intervention. Nonetheless, it
is hypothesized that improvements in cancer-related
247
outcomes are possible, and likely probable, through

intentional weight reduction in overweight or obese cancer
survivors.92 Currently a National Cancer Institute-funded
vanguard study is underway (Exercise and Nutrition to
Enhance Recovery and Good Health for You [ENERGY])
(1R01 CA 148791-01) to test the feasibility and impact on
quality of life of a diet and exercise weight management
intervention in 800 overweight and obese breast cancer survivors, as well as set the stage for a larger study examining
the effects of weight loss on survival and other cancer outcomes. Evidence already exists that weight loss that results
from intentional exercise and caloric restriction can improve
the hormonal milieu93,94 and quality of life and physical
functioning among survivors who are obese or overweight.95
It may be difficult for individuals to pursue a host of new dietary, exercise, and behavioral strategies to reduce body
weight through reduced energy intake and increased energy
expenditure while at the same time balancing the demands
of daily life during initial treatments.96 Thus, for many, active
efforts toward intentional weight loss may be postponed until
surgery, chemotherapy, and/or radiation treatment is complete. However, for cancer survivors who are overweight or
obese and who choose to pursue weight loss, there appears to
be no contraindication to modest weight loss (ie, a maximum
of 2 pounds per week)97 during treatment, as long as the
treating oncologists approve, weight loss is monitored
closely, and it does not interfere with treatment. Past
studies showing deleterious associations with decreases in
body weight after diagnosis have been unable to separate
intentional from nonintentional weight loss. Safe weight
loss should be achieved through a nutritious diet that is
reduced in energy density and increased physical activity
tailored to the specific needs of the patient.7,28,98
After cancer treatment, weight gain or loss should be
managed with a combination of dietary, physical activity,
and behavioral strategies. For some who need to gain
weight, this means increasing energy intake to exceed
energy expended and for others who need to lose weight,
reducing caloric intake and increasing energy expenditure
via increased physical activity to exceed energy intake.
Reducing the energy density of the diet by emphasizing
low-energy dense foods (eg, water- and fiber-rich vegetables
and fruits) and limiting the intake of foods and beverages
high in fat and added sugar promotes healthy weight
control.99 Limiting portion sizes of energy-dense foods is
an important accompanying strategy.99 Increased physical
activity is also an important element to prevent weight
gain, retain or regain muscle mass, promote weight loss,
and promote the maintenance of weight loss in patients
who are overweight or obese. For survivors who are severely
obese and have more pressing health issues, more structured
weight loss programs or pharmacologic or surgical means
may be indicated.100 It should be noted that among those
248
who need to lose weight, even if ideal weight is not

achieved, it is likely that any weight loss achieved by physical activity and healthful eating is beneficial, with weight
losses of 5% to 10% still likely to have significant health
benefits.90,99,100 Although most evidence related to these
weight management strategies does not come from studies
of cancer survivors per se, it is likely that these approaches
can apply in the special circumstances of the cancer
survivor.
Throughout the cancer continuum, therefore, individuals
should strive to achieve and maintain a healthy weight, as
defined by a body mass index (BMI) (Table 3) between
18.5 kg/m2 and 25 kg/m2. Some cancer survivors can be
malnourished and underweight at diagnosis or as a result of
aggressive cancer treatments.101 For these individuals,
further weight loss can impair their quality of life, interfere
with the completion of treatment, delay healing, and
increase the risk of complications. In survivors with these
difficulties, dietary intake and factors affecting energy
expenditure should be carefully assessed.13,58-60 For those at
risk of unintentional weight loss, multifaceted interventions
should focus on increasing food intake to achieve a positive
energy balance and therefore increase weight.13,58-60 Physical
activity may be useful to the underweight survivor when
tailored to provide stress reduction and to increase strength
and lean body mass, but exceptionally high levels of physical
activity make weight gain more difficult.102
Physical Activity in Cancer Survivors

Since the 2006 update of these guidelines for cancer survivors,
there has been a marked increase in the number of studies that
have addressed the association between physical activity and a
variety of outcomes in patients who have completed the initial
phase of therapy for their cancer.27,63,76 The outcomes of
interest in this update include cancer recurrence, cancer-specific
and overall survival, health-related fitness, patient-reported
outcomes, lymphedema, and comorbid conditions.28
Prospective, observational studies have demonstrated that
physical activity after cancer diagnosis is associated with a
reduced risk of cancer recurrence and improved overall
mortality among multiple cancer survivor groups, including
breast, colorectal, prostate, and ovarian cancer.62,64,65,103-107
Among breast cancer survivors, physical activity after
diagnosis has consistently been associated with reduced risk
of breast cancer recurrence and breast cancer-specific
mortality. A recent meta-analysis demonstrated that postdiagnosis exercise was associated with a 34% lower risk of
breast cancer deaths, a 41% lower risk of all-cause mortality,
and a 24% lower risk of breast cancer recurrence.62 Among
survivors of colorectal cancer, at least 4 large cohort studies
have found an inverse association between being physically
active after diagnosis and recurrence, colorectal cancer-specific
TABLE 3. Adult BMI Chart

BMI
19
20
21
22
23
24
25
HEIGHT
0
26
27
28
29
30
31
32
33
34
35
WEIGHT IN POUNDS
00
4 10
91
96
100
105
110
115
119
124
129
134
138
143
148
153
158
162
167
40 1100
94
99
104
109
114
119
124
128
133
138
143
148
153
158
163
168
173
97
102
107
112
118
123
128
133
138
143
148
153
158
163
168
174
179
0 00
100
106
111
116
122
127
132
137
143
148
153
158
164
169
174
180
185
0 00
104
109
115
120
126
131
136
142
147
153
158
164
169
175
180
186
191
0 00
53
107
113
118
124
130
135
141
146
152
158
163
169
175
180
186
191
197
50 400
110
116
122
128
134
140
145
151
157
163
169
174
180
186
192
197
204
0 00
114
120
126
132
138
144
150
156
162
168
174
180
186
192
198
204
210
0 00
118
124
130
136
142
148
155
161
167
173
179
186
192
198
204
210
216
0 00
121
127
134
140
146
153
159
166
172
178
185
191
198
204
211
217
223
0 00
58
125
131
138
144
151
158
164
171
177
184
190
197
203
210
216
223
230
50 900
128
135
142
149
155
162
169
176
182
189
196
203
209
216
223
230
236
51
52
55
56
57
00
132
139
146
153
160
167
174
181
188
195
202
209
216
222
229
236
243
00
5 10
5 11
136
143
150
157
165
172
179
186
193
200
208
215
222
229
236
243
250
140
147
154
162
169
177
184
191
199
206
213
221
228
235
242
250
258
0 00
61
144
151
159
166
174
182
189
197
204
212
219
227
235
242
250
257
265
60 200
148
155
163
171
179
186
194
202
210
218
225
233
241
249
256
264
272
0 00
152
160
168
176
184
192
200
208
216
224
232
240
248
256
264
272
279
63
HEALTHY WEIGHT
OVERWEIGHT
OBESE
BMI indicates body mass index.

Source: US Department of Health and Human Services, National Institutes of Health, National Health, Lung, and Blood Institute. the Clinical Guidelines on the
Identification, Evaluation and Treatment of Overweight and Obesity in Adults: Evidence Report. NIH Pub. No. 98-4083. Bethesda, MD: US Department of Health
and Human Services, National Institute of Health, National Health, Lung, and Blood Institute; 1998.
mortality and/or overall mortality, with improvements of up

to 50% for each outcome.104-107 There is now a randomized,
phase 3 trial underway comparing a physical activity program
with health education in survivors of stage II and III colon
cancer after standard chemotherapy.108
Exercise has been shown to improve health-related
fitness outcomes in several cancer survivor groups. As a
result of both their cancer and treatment, cancer patients
are often in a deconditioned state. Aerobic and resistance
training consistently show a benefit for cardiopulmonary
fitness, muscle strength, body composition, and balance.27
A substantial number of randomized controlled trials have
tested the effects of physical activity after diagnosis on various
patient-reported outcomes. In many studies, exercise improves
quality of life, fatigue, psychosocial distress, depression, and
self-esteem. For example, in one randomized study in men
with prostate cancer who were undergoing androgen suppression therapy, those assigned to a program of resistance and
aerobic training had increases in lean mass, improved muscle
strength, improved walk time, and improved balance,26 and in
a randomized controlled trial of breast cancer survivors,
women assigned to moderate intensity resistance and impact

training experienced improvements in bone mass and lean
muscle mass.33
A recent meta-analysis of 78 exercise intervention trials
showed that exercise interventions resulted in clinically meaningful improvements in quality of life that persisted after the
completion of the intervention.109 In another meta-analysis
of 44 studies that included over 3000 participants with
varying cancer types, cancer survivors randomized to an
exercise intervention had significantly reduced cancerrelated fatigue levels, with evidence of a linear relationship
to the intensity of resistance exercise.110
Historically, there were concerns that cancer survivors with
upper extremity lymphedema should not engage in upper
extremity resistance training or vigorous aerobic physical
activity. There are now multiple trials that have demonstrated
that such physical activity is not only safe, but actually reduces
the incidence and severity of lymphedema.29,111,112
Many cancer survivors have an increased risk of comorbid
conditions that can be reduced through increased physical
activity.113,114 The effects of physical activity on cardiovascular
249
disease and diabetes have not been studied in cancer survivors,

but it is reasonable to expect that the beneficial effects of
physical activity on such outcomes would not differ from
those observed in the general population.
Despite the many benefits of exercise for cancer survivors,
particular issues may affect the ability of survivors to
exercise. Effects of treatment may also increase the risk of
exercise-related injuries and adverse effects, and therefore
specific precautions may be advisable, including:
Survivors with severe anemia should delay exercise,
other than activities of daily living, until the anemia is
improved.
Survivors with compromised immune function should
avoid public gyms and public pools until their white
blood cell counts return to safe levels. Survivors who
have completed a bone marrow transplant are usually
advised to avoid such exposures for one year after
transplantation.
Survivors experiencing severe fatigue from their therapy
may not feel up to an exercise program, and therefore
they may be encouraged to do 10 minutes of light
exercises daily.
Survivors undergoing radiation should avoid chlorine
exposure to irradiated skin (eg, from swimming pools).
Survivors with indwelling catheters or feeding tubes
should be cautious or avoid pool, lake, or ocean water or
other microbial exposures that may result in infections,
as well as resistance training of muscles in the area of the
catheter to avoid dislodgment.
Survivors with multiple or uncontrolled comorbidities
need to consider modifications to their exercise program
in consultation with their physicians.
Survivors with significant peripheral neuropathies or
ataxia may have a reduced ability to use the affected limbs
because of weakness or loss of balance. They may do
better with a stationary reclining bicycle, for example,
than walking on a treadmill.
After consideration of these and other specific precautions,
it is recommended that cancer survivors follow the
survivor-specific guidelines written by an expert panel
convened by the American College of Sports Medicine
(ACSM).28 The ACSM panel recommended that individuals avoid inactivity and return to normal activity as soon as
possible after diagnosis or treatment. For aerobic physical
activity, the ACSM panel recommended that survivors
follow the US Department of Health and Human Services
2008 Physical Activity Guidelines for Americans.114 According to those guidelines, adults aged 18 to 64 years should
engage in at least 150 minutes per week of moderate
intensity or 75 minutes per week of vigorous intensity aerobic
physical activity, or an equivalent combination of moderate
and vigorous intensity aerobic physical activity (Table 4).
Some activity is better than none and exceeding the
250
guidelines is likely to provide additional health benefits.

Activity should be done in episodes of at least 10 minutes per
session and preferably spread throughout the week. Furthermore, adults should do muscle-strengthening activities
involving all major muscle groups at least 2 days per week.
Adults aged older than 65 years should also follow these
recommendations if possible, but if chronic conditions limit
activity, older adults should be as physically active as their
abilities allow and avoid long periods of physical inactivity.
Cancer type-specific recommendations will be discussed in
the individual cancer sections below.
Supporting Exercise Behavior Change

Based on the current evidence, cancer care professionals can
expect that fewer than 10% of cancer survivors will be active
during their primary treatments and only about 20% to
30% will be active after they recover from treatments.115,116
Consequently, unless behavioral support interventions are
provided, the majority of cancer survivors will not benefit
fully from regular physical activity. Behavioral support
interventions to assist cancer survivors in adopting and
maintaining a physically active lifestyle have been reviewed
elsewhere.115-117 Some successful strategies include shortterm supervised exercise (eg, 12 weeks), support groups,
telephone counseling, motivational interviewing, and
cancer survivor-specific print materials. The key point for
cancer care professionals is that cancer survivors have
unique motives, barriers, and preferences for physical
activity. Table 4 shows examples of moderate and vigorous
intensity activities.118
Dietary and Food Choices

As summarized in recent reviews, results from observational
studies suggest that diet and food choices may affect cancer
progression, risk of recurrence, and overall survival in individuals who have been treated for cancer.3,7,98,119 Breast
cancer survivors have been the focus of the majority of these
studies, although a growing number of studies involving
cohorts of colorectal and prostate cancer survivors have
been conducted and published over the past decade. The
majority of this research has focused on the effect of
individual nutrients, bioactive food components, or specific
foods. Disentangling the effects of these dietary constituents
and related lifestyle factors and characteristics (eg, physical
activity, obesity) that influence risk and progression of cancer
has proved to be very challenging. Furthermore, people
eat food, not nutrients, and even specific foods are
generally consumed in a pattern that is characterized by
several features and bioactive components that potentially
influence cancer progression. Evaluating the relationship
between survival and diet as a dietary pattern rather than
by focusing only on specific foods may also be informative.
TABLE 4. Examples of Moderate and Vigorous Activities118

MODERATE ACTIVITIES (I CAN TALK WHILE I DO THEM, BUT I CANT SING)
l
l
l
l
l
l
l
l
l
l
Ballroom and line dancing

Biking on level ground or with few hills
Canoeing
General gardening (raking, trimming shrubs)
Sports where you catch and throw (baseball, softball, volleyball)
Tennis (doubles)
Using your manual wheelchair
Using hand cyclers (also called ergometers)
Walking briskly
Water aerobics
VIGOROUS ACTIVITIES (I CAN ONLY SAY A FEW WORDS WITHOUT STOPPING

TO CATCH MY BREATH)
l
l
l
l
l
l
l
l
l
l
l
For example, a dietary pattern high in fruits, vegetables,

whole grains, poultry, and fish was found to be associated
with reduced mortality compared with a dietary pattern
characterized by a high intake of refined grains, processed
and red meats, desserts, high-fat dairy products, and French
fries in women after breast cancer diagnosis and treatment.120 Similarly, a 43% reduction in overall mortality was
observed in a study of breast cancer survivors in association
with a dietary pattern characterized by the high intake
of vegetables and whole grains.121 Breast cancer survivors
who reported eating at least 5 servings of vegetables and
fruits each day and having weekly physical activity equivalent to 30 minutes of walking for 6 days per week were
observed to have a higher survival rate, although a significant survival advantage was not observed for either of these
behaviors alone.122 In patients with colorectal cancer, one
observational study of over 1000 survivors found that a diet
characterized by a higher intake of red meat, processed
meat, refined grains, and sugary desserts was associated with
a statistically significant increase in cancer recurrence and
poorer overall survival.123
Diet Composition
Protein, carbohydrate, and fat all contribute energy to the
diet, and each of these dietary constituents is available from
a wide variety of foods. Because many cancer survivors are
at high risk of other chronic diseases, such as heart disease,
the recommended amounts and types of fat, protein, and
carbohydrate to reduce cardiovascular disease risk are also
appropriate for cancer survivors, particularly if they are at or
above their recommended body weight.46,47,49,52
The Institute of Medicine and current Federal Guidelines,
as well as the American Heart Association (AHA), recommend a spectrum of dietary composition for the adult
population: fat: 20% to 35% of energy (AHA: 25%-35%),
carbohydrate: 45% to 65% of energy (AHA: 50%-60%); and
protein: 10% to 35% of energy (at least 0.8 g/kg).46,49,124
Several studies have examined the relationship between
fat intake and survival after the diagnosis of breast
cancer; evidence from these observational studies is mixed.
Aerobic dance
Biking faster than 10 miles per hour
Fast dancing
Heavy gardening (digging, hoeing)
Hiking uphill
Jumping rope
Martial arts (such as karate)
Race walking, jogging, or running
Sports with a lot of running (basketball, hockey, soccer)
Swimming fast or swimming laps
Tennis (singles)
Inverse associations have been found between fat intake

and recurrence and/or survival in some of these studies,
although these associations typically disappear with energy
adjustment.98,125,126 A U-shaped relationship between
dietary fat intake and mortality following the diagnosis of
breast cancer was identified in one observational study,127
suggesting that extremes in fat intake may be associated
with poorer outcomes.
Two large randomized controlled trials have tested
whether a reduction in fat intake following the diagnosis of
early stage breast cancer affects cancer outcomes. The WINS
tested a low-fat diet (aiming for less than 15% of energy) in
2437 postmenopausal women with early stage breast cancer
and found an effect on relapse-free survival that was of
borderline statistical significance.91 On average, the women
in the intervention arm decreased their fat intake to 20% of
energy at year one, and the intervention resulted in a 24%
reduction in new breast cancer events, with subset analyses
suggesting that this effect was greater among women with
ER-negative disease. Of note, as previously described, women
assigned to the low-fat diet study arm lost an average of 6
pounds over the course of the study, thus confounding
whether the reduction in breast cancer events was due to
dietary fat restriction or lower body weight.
The Womens Healthy Eating and Living (WHEL)
Study tested the effect of a diet low in fat (aiming for 20%
of energy intake) and very high in vegetables, fruits, and
fiber on cancer outcomes in 3088 pre- and postmenopausal
breast cancer survivors who were followed for an average of
7.3 years.122 At 4 years, women in the intervention group
reported a reduction in fat intake (from 31.3% at enrollment
to 26.9% of energy intake), but recurrence-free survival did
not differ between the 2 study arms.122 Notably, women in
the WHEL Study intervention group did not exhibit weight
loss, in contrast to the low-fat diet intervention group in
WINS. The WHEL Study intervention was observed to
improve prognosis in women without hot flashes when
enrolled in the study, and who were therefore likely to have
higher circulating estrogen concentrations,128 suggesting
that there may be survival benefits for this subgroup.
251
A few observational follow-up studies of diet and survival

after the diagnosis of prostate cancer have also been reported.
In one of these studies, a higher saturated fat intake predicted
shorter disease-specific survival and in another, greater
monounsaturated fat intake predicted longer survival.129,130
Given that men with prostate cancer are at a significant risk
of death due to cardiovascular disease, these heart-healthy
recommendations appear prudent not only for cancer
prevention but also for competing causes of death.
Some studies have suggested that omega-3 fatty acids may
have specific benefits for cancer survivors, such as ameliorating cachexia, improving quality of life, and perhaps enhancing
the effects of some forms of treatment.131,132 These findings
are not entirely consistent, however, and more research is
needed.133 Regardless, including foods that are rich in
omega-3 fatty acids (eg, fish, walnuts) in the diet should be
encouraged, because this is associated with a lower risk of
cardiovascular diseases and a lower overall mortality rate.46,49
Adequate protein intake is essential during all stages of
cancer treatment, recovery, long-term survival, and living
with advanced disease. The best choices to meet protein
needs are foods that are also low in saturated fat (eg, fish,
lean meat, skinless poultry, eggs, nonfat and low-fat dairy
products, nuts, seeds, and legumes).
Vegetarian diets can be healthy or unhealthy, depending
on ones food choices. Vegetarian diets differ with respect to
the inclusion of dairy foods, fish, and/or eggs, but avoiding
red meat is a universal feature. Fish, dairy foods, or both
contain a sufficient quantity and quality of protein, and a
vegetarian diet that contains these foods typically has a nutrient content similar to an omnivorous diet. A vegan diet,
which excludes all animal foods and animal products, can
meet protein needs if nuts, seeds, legumes, and cereal-grain
products are consumed in sufficient quantities, although
supplemental vitamin B12 will be necessary to meet needs
for that vitamin. As dietary vitamin D in the United States
comes primarily from fortified dairy foods, a vegan diet may
also need to include supplemental vitamin D if adequate exposure to the sun or ultraviolet light is not obtained. No
direct evidence has helped to determine whether consuming
a vegetarian diet has any additional benefit for the prevention
of cancer recurrence over an omnivorous diet high in vegetables, fruits, and whole grains, and low in red meats.
Healthy carbohydrate sources are foods that are rich in
essential nutrients, phytochemicals, and fiber, such as
vegetables, fruits, whole grains, and legumes. These foods
should provide the majority of carbohydrate in the diet.
Whole grains are rich in a variety of compounds (in addition
to fiber) that have important biologic activity, including
hormonal and antioxidant effects. For example, whole
grains contain antioxidants, such as phenolic acids, flavonoids, and tocopherols; compounds with weak hormonal
252
effects such as lignans; and compounds that may influence

lipid metabolism, such as phytosterols and unsaturated fatty
acids. All of these compounds and their biologic effects have
been hypothesized to reduce the risk and progression of cancer
as well as cardiovascular disease.134 Choosing whole grains and
whole-grain food products as a source of fiber, rather than
relying on fiber supplements, adds nutritional value to the diet.
Refined grains have been milled, a process that removes the
bran and germ. This results in levels of vitamins, minerals, and
fiber that are lower than those in the unrefined, whole-grain
counterpart. Examples of refined grain products include white
flour, degermed cornmeal, white bread, and white rice. In
the United States, most refined grain products have been
enriched, which means that micronutrients such as thiamin,
riboflavin, niacin, iron, and folate have been added back to
the product after processing. Thus, they are not completely
without nutritional value, but many of the potentially
helpful constituents, such as fiber and biologically active
phytochemicals, have not been added back.
High sugar intake has not been shown to increase the risk
or progression of cancer. However, sugars (including honey,
raw sugar, brown sugar, high-fructose corn syrup, and
molasses) and beverages that are major sources of these sugars
(such as soft drinks and many fruit-flavored drinks) add
substantial amounts of calories to the diet and thus can promote
weight gain. In addition, most foods that are high in added
sugar do not contribute many nutrients to the diet and often
replace more nutritious food choices. Therefore, limiting the
consumption of products with added sugar is recommended.
Vegetables and fruits contain numerous dietary constituents
that potentially inhibit cancer progression, such as essential
vitamins and minerals, biologically active phytochemicals, and
fiber. In addition, these are lowenergy-dense foods that
promote satiety, and thus may promote healthy weight
management.135 Whole fruit (instead of juice) adds more fiber
and fewer calories to the diet. When fruit juice is chosen,
100% fruit juice is the best choice.
As noted above, results from more recent studies suggest
that a dietary pattern that is rich in vegetables and fruits is
associated with increased overall survival following cancer
diagnosis and treatment.120 In addition to being rich in
vegetables and fruits, this dietary pattern is characterized as
having more fish and poultry rather than red meat and
processed meat, low-fat rather than full-fat dairy products,
whole grains rather than refined grain products, and tree
nuts and olive oil rather than other sources of fat. A study
of colon cancer survivors found that a Western diet characterized by high intakes of meat and added sugars, was
associated not only with poorer cancer-specific survival, but
a reduced likelihood of overall survival as well.123
In the observational studies that have examined the
relationship between intakes of vegetables and fruits (or
nutrients indicative of those foods) and the risk of breast
cancer recurrence, the findings have been mixed.136 The

WHEL Study tested the effect of a diet very high in
vegetables, fruits, and fiber on the risk of recurrence and
overall survival in early stage breast cancer survivors who
reported a high average intake of vegetables and fruits (7.3
servings/ay) at enrollment. At 6 years, the intervention
group had increased to an average of 9.2 servings per day,
whereas the control group averaged 6.2 servings per day,
yet recurrence-free survival did not differ between the 2
study arms.122 However, serum estrogen levels at baseline
were independently associated with poor prognosis, and a
protective effect of the diet was observed in the subgroup of
women who did not report hot flashes at enrollment (an
indication of higher estrogen levels).128 These findings
suggest that reproductive hormonal status may determine
whether a diet high in vegetables, fruits, and fiber affects
prognosis. In addition, longitudinal exposure to carotenoids
was associated with breast cancer-free survival regardless
of study group assignment.137 Thus, diet prior to the
diagnosis of cancer and over the long term may be more
important than short-term dietary changes postdiagnosis.
A few studies have evaluated the association between diet
and ovarian cancer survival.138 A higher prediagnosis intake of
vegetables, especially yellow and cruciferous vegetables, was
associated with longer survival in these studies.139,140 A single
observational study of diet after diagnosis and risk of prostate
cancer progression found those men who consumed
more tomato sauce had longer survival.141 The benefits of
eating a variety of vegetables and fruits probably exceed the
health-promoting effects of any individual constituents in
these foods because the various vitamins, minerals, and other
phytochemicals in these whole foods act in synergy. Current
public health recommendations for adults are to eat at least
2 to 3 cups of vegetables and 1.5 to 2 cups of fruits each day.
Colorful choices such as dark green and orange vegetables
are good sources of nutrients and potentially healthful
phytochemicals. Fresh, frozen, canned, raw, cooked, or dried
vegetables and fruits all contribute nutrients and other
biologically active constituents to the diet. Cooking vegetables
and fruits, especially with methods such as microwaving or
steaming in preference to boiling in large amounts of
water, preserves the bioavailability of water-soluble nutrients
and can improve the absorption of others. For example,
carotenoids are better absorbed from cooked vegetables than
from raw vegetables. There is no evidence that organically
grown vegetables and fruits are superior in their content of
potential cancer-preventive constituents.
Dietary Supplements
According to the Dietary Supplement Health and Education
Act (DSHEA) of 1994, dietary supplements include vitamins;
minerals; herbs/botanicals; amino acids; and a concentrate,
metabolite, constituent extract, or combination of any of
the aforementioned. Dietary supplement use is reported by

52% of US adults142 and studies report ranges between 64%
and 81% among cancer survivors.98,143 A recent systematic
review indicates that 14% to 32% of cancer survivors initiate
supplement use after their diagnosis.143 Breast cancer survivors report the highest prevalence of supplement use, whereas
prostate cancer survivors report the lowest.143 Cancer survivors use supplements for a variety of reasons, including
following the advice of health care providers or others, treating a symptom, to feel better, and/or as general insurance of
adequate nutrient intake.144,145
Evidence from both observational studies and clinical
trials suggests that dietary supplements are unlikely to
improve prognosis or overall survival after the diagnosis of
cancer, and may actually increase mortality. A 2006 metaanalysis found no association between antioxidant or
vitamin A supplementation and all-cause mortality among
cancer patients, although the authors noted that this report
was limited by the small number of trials, particularly those
of high quality.146 The use of multivitamins or vitamins E
or C was not associated with protection from cancer death
in a cohort of 77,719 Washington state residents followed
over a 10-year period.147 In 2 large observational studies,
the use of a full range of dietary supplements or multivitamins in particular was not associated with breast cancer
recurrence, breast cancer-specific mortality, or overall
mortality among women diagnosed with early stage breast
cancer.148,149 A similar finding was reported for multivitamin use among colorectal cancer survivors.150 In addition,
one trial suggests that beta-carotene supplements may
increase the rate of colorectal adenoma recurrence in persons who smoke cigarettes, consume alcohol, or both.151 A
randomized clinical trial of 540 head and neck cancer
patients receiving radiation therapy in which participants
were randomized to either 400 IU/day of vitamin E or
placebo found that supplement use was associated with significantly higher cause-specific and all-cause mortality.152
In addition, the recent Selenium and Vitamin E Cancer
Prevention Trial (SELECT) found that men who were
assigned supplemental selenium or vitamin E had a higher
incidence of diabetes and prostate cancer, respectively.153
Some observational studies have reported that breast
cancer survivors have high rates of vitamin D insufficiency,154 suggesting the need for vitamin D supplementation. Although supplemental vitamin D may help to meet
nutritional needs for this vitamin, circulating concentrations have not been shown to affect the risk of breast cancer
recurrence.155 Two observational studies have found that a
higher circulating prediagnosis vitamin D or higher postdiagnosis vitamin D level is associated with significant
improvements in overall and/or colorectal cancer-specific
mortality among colorectal cancer survivors.156,157 A
recent review, however, suggests that taking vitamin D
253
254
supplements has not been proven to improve outcomes in

cancer patients.158 These findings underscore the need to
first assess whether nutrient status is indeed deficient before
initiating supplements, since individuals who are truly
deficient may derive some benefit, whereas those who take
additional supplements but who are already well-nourished
are unlikely to benefit and may incur harm.
Although the use of standard multiple vitamin and
mineral supplements has previously been recommended
during and after treatment as an insurance policy for
obtaining adequate amounts of nutrients, this practice has
recently come under scrutiny as more recent data suggest
that multivitamin supplements may actually increase the
risk of mortality among healthy individuals or, at the very
least, may not be helpful.150,159-162 The current body of
evidence regarding supplement use by cancer survivors
suggests that some general guidance should be considered:
Before supplements are prescribed or taken, all attempts
should be made to obtain needed nutrients through
dietary sources.
Supplements should be considered only if a nutrient
deficiency is either biochemically (eg, low plasma vitamin
D levels, B12 deficiency) or clinically (eg, low bone
density) demonstrated.
Supplements should be considered if nutrient intakes
fall persistently below two-thirds of the recommended
intake levels. Such a determination should be made by
a registered dietitian, who is most qualified to assess
the nutrient adequacy of the diet, especially in view of
emerging data suggesting that higher nutrient intakes,
especially through sources other than foods, may be
harmful rather than helpful.
Open dialogue between patients and health care providers
should occur regarding dietary supplementation to ensure
there is no contraindication in relation to the prescribed
cancer therapy or for longer term health effects.163,164 In
turn, health care providers should make an effort not only to
provide time to review dietary supplement decisions with
patients, but also to stay abreast of recent research in this
area, particularly that related to potential drug interactions.
It is most prudent to encourage cancer survivors to obtain
the potentially beneficial compounds from food.
alcohol consumption to the individual cancer survivor. The

cancer type and stage of disease, treatment, treatment-related
side effects, risk factors for recurrence or new primary
cancers, and comorbid conditions should be considered in
making recommendations. Many health care professionals
ask individuals receiving chemotherapy or biological therapy
to avoid alcohol consumption during treatment. This advice
is also often given if receiving radiation therapy to the head,
neck, or thoracic region. For example, during the time of
active treatment, alcohol, even in the small amounts found
in mouthwashes, can be irritating to survivors with oral
mucositis and can exacerbate that condition. Therefore, it is
reasonable to recommend that alcohol intake should be
avoided or limited among survivors with mucositis and
among those beginning head and neck radiation therapy
or chemotherapeutic regimens that put them at risk for
mucositis. Among cancer survivors, the prevalence of alcohol
use generally mirrors that in the general population, although
among some survivor groups (ie, survivors of prostate and
head and neck cancers) it is higher.169
The link between alcohol intake and risk of some primary
cancers has been established, including cancers of the
mouth, pharynx, larynx, esophagus, liver, and breast and,
for some forms of alcohol beverages, colon cancer.47,165,170
In individuals who have already received a diagnosis of
cancer, alcohol intake could also increase their risk of new
primary cancers of these sites171; moreover, a long-standing
literature in patients with head and neck cancer suggests
that continued alcohol consumption (as well as smoking)
leads to lower survival rates, thus supporting the need to
limit alcohol consumption in this population.168,172 In
breast cancer, the relationship with alcohol intake after
diagnosis is less clear, although there is irrefutable evidence
that alcohol intake is linearly associated with primary risk.52
Alcohol intake can increase the circulating levels of
estrogens, which theoretically could increase the risk of
recurrence of breast cancer. To date, a few studies have
explored outcomes of breast cancer survivors by alcohol intake.
The results are mixed, with some studies173-175 suggesting
that alcohol confers a protective effect on overall survival
and subsequent ovarian cancer, and others176,177 finding an
increased risk of contralateral disease and disease-specific
and overall mortality.
Alcohol
Food Safety
Substantial observational evidence indicates that alcohol

intake has both positive and negative health effects.47,165-167
Alcoholic drinks up to one or 2 drinks per day (for women
and men, respectively) can lower the risk of heart disease,
but higher levels do not offer additional benefit and may
increase the risk not only of complications of alcohol
overuse, but also of specific cancers.168 For this reason, it is
important for the health care provider to tailor advice on
Food safety is of special concern for cancer survivors,

especially during episodes of treatment-related immunosuppression that can occur with certain cancer treatment
regimens.178 Survivors can become susceptible to developing
infections due to treatment-induced leukopenia and
neutropenia. During any immunosuppressive cancer treatment, survivors should take extra precautions to prevent
infection, and they should be particularly careful to avoid
TABLE 5. General Guidelines for Food Safety

Wash hands with soap and water thoroughly before eating.
Keep all aspects of food preparation clean, including washing hands before food preparation and washing fruits and vegetables thoroughly.
l Use special care in handling raw meats, fish, poultry, and eggs.
l Thoroughly clean all utensils, countertops, cutting boards, and sponges that have contact with raw meat; keep raw meats and ready-to-eat foods separate.
l Cook to proper temperatures; meats, poultry, and seafood should be thoroughly cooked and beverages (milk and juices) should be pasteurized.
Use a food thermometer to check internal temperatures of meats before serving.
l Store foods promptly at low temperatures (below 40 F) to minimize bacterial growth.
l When eating in restaurants, avoid foods that may have potential bacterial contamination such as items from salad bars; sushi; or raw or undercooked meat,
fish, shellfish, poultry, and eggs.
l Avoid raw honey, milk, and unpasteurized fruit juice, and choose pasteurized versions instead.
l If there is any question or concern about water purity (eg, well water), it can be checked for bacterial content by contacting your local public
health department.
l
l
eating foods that may contain unsafe levels of pathogenic

microorganisms. By following safe food practices, cancer
survivors and their caregivers can reduce the risk of
foodborne illness. General guidelines for food safety, as
shown in Table 5, should be followed.
Nutrition and Physical Activity Issues

by Selected Cancer Sites
Breast Cancer
For a woman diagnosed with breast cancer, achieving or
maintaining a desirable weight may be one of the most
important lifestyle pursuits. The majority of studies
conducted over several decades indicate that overweight or
obesity at the time of diagnosis is a poor prognostic factor
and may be associated with less favorable lymph node
status, as well as a variety of undesirable outcomes (eg,
contralateral disease, recurrence, comorbid disease, and/or
disease-specific or overall mortality, as well as treatment
effects such as lymphedema).8,54,87,179-186 Given that overweight and obesity are well-established risk factors for
worse prognosis, and many women are overweight when
diagnosed with breast cancer, weight management is a
concern for a substantial percentage of breast cancer survivors. A compounding problem is the fact that additional
weight gain is frequently reported after diagnosis.187-189
Analyses conducted on a cohort of nonsmoking breast cancer survivors within the Nurses Health Study corroborated
these findings. Women who increased their BMI by 0.5 to
2 units were found to have a 40% greater chance of recurrence, and those who gained more than 2 BMI units had a
53% greater chance of recurrence compared with those who
did not gain more than 0.5 BMI units.86 In that study,
survivors in whom weight decreased did not experience
significantly poorer outcomes. However, other recent studies
have not found an effect of weight gain on prognosis.190
Although it must be considered that unexplained weight
loss may be a symptom of recurrent disease and should be
monitored closely,191 there is a vast difference between
weight loss that is intentional or purposeful versus that
which is unexplained or a consequence of disease. Indeed,

given accumulating data to suggest that overweight and
obesity adversely influence not only cancer-specific outcomes but also overall health and quality of life, weight
management is now considered a priority standard of care
for overweight women diagnosed with early stage breast
cancer.8,192 A decade of previous research,193-196 as well as
more recent studies, also suggests that the weight gain
experienced by women who have been treated with adjuvant chemotherapy or hormonal treatment seems to be the
result of increased adipose tissue mass, with no change or a
decrease in lean body mass.82,189,197,198 This unfavorable
shift in body composition suggests that interventions
should be aimed at not only curbing weight gain during
treatment but also at preserving or rebuilding muscle mass.
Moderate physical activity (especially resistance training)
during and after treatment may help survivors maintain
lean muscle mass while avoiding excess body fat.188,199
Even if an ideal weight is not achieved, it has been established in the general population that a weight loss of 5% to
10% over 6 to 12 months is sufficient to reduce the levels of
factors associated with chronic disease risk, such as elevated
plasma lipids and fasting insulin levels.90 Furthermore, a
recent review of the scientific literature documented that
intentional weight loss promotes favorable changes in
breast cancer-relevant biomarkers, such as estrogens, sex
hormone-binding globulin, and inflammatory markers.200
There is substantial research on physical activity in breast
cancer survivors and multiple systematic reviews focused on
its role in these individuals.62,201 In a meta-analysis of 717
breast cancer survivors participating in 14 randomized
controlled trials, physical activity led to statistically significant improvements in quality of life, physical functioning,
and peak oxygen consumption, as well as a reduction in
symptoms of fatigue.201 Another meta-analysis of 6 prospective cohort studies that included over 12,000 breast cancer
survivors showed that postdiagnosis physical activity was
associated with a 24% and 34% lower rate of breast cancer
recurrence and mortality, respectively, and a 41% lower rate
of all-cause mortality. Despite these promising findings,
255
there remains a need for a randomized controlled trial to further test the benefit of exercising in preventing cancer recurrence and improving survival in women with breast cancer.62
Even with the increased use of sentinel lymph node
dissection, lymphedema remains a concern among breast
cancer survivors. However, aerobic physical activity and
resistance training appear to be both safe and effective in
reducing the incidence of lymphedema among survivors at
high risk of this condition, and in improving the symptoms
and severity of lymphedema for those in whom the condition
was preexisting.111,112 Progressive resistance training under
the supervision of a trained exercise therapist and using
appropriate compression garments is recommended. In addition, because obesity is a major risk factor for lymphedema,
weight loss is recommended among survivors who are
overweight or obese.
Research is currently under way to evaluate various
components of dietary patterns on cancer-specific outcomes,
as well as overall health. An observational study found that
dietary pattern was important for overall survival among
breast cancer survivors, with those who ate a Western diet
having poorer overall survival and those who ate a dietary
pattern characterized by high amounts of fruits, vegetables,
and whole grains having better overall survival; however,
neither dietary pattern was associated with breast cancer
recurrence specifically.120 One factor that tends to separate
these 2 dietary patterns is fat; however, to date, evidence
that dietary fat intake could be associated with risk of
recurrence or survival is not strongly or consistently
supported, especially when total energy intake and the
degree of obesity are considered.202,203
Two large clinical trials tested whether change in diet
composition can reduce the risk of recurrence and increase
overall survival in women who have been diagnosed with
breast cancer. While the WINS low-fat dietary intervention group exhibited a borderline significant 24% reduction
in risk of recurrence, the group also lost weight, so it is
possible that the benefits were due to weight loss and not a
reduction in fat intake. In the WHEL Study, a reduction
in dietary fat was among the dietary goals, and an effect of
the diet intervention (which was not associated with weight
loss) was not observed.
Eating more vegetables is inconsistently related to reducing
breast cancer risk, and the evidence that fruit intake is related
to recurrence or survival is weak.204,205 In the WHEL Study,
the major intervention was increased vegetable and fruit
intake, although women in the intervention group were also
encouraged to reduce their fat and increase their fiber
intakes.206 Recurrence-free survival did not differ between
the 2 study arms in that study,122 although the fruit and
vegetable intake of these women was already high, averaging
greater than 7 servings per day at the beginning of the study.
256
The WHEL Study intervention did improve prognosis in

women without hot flashes when enrolled in the study,128
suggesting that there may be survival benefits among women
with higher circulating estrogen levels. Also, longitudinal
exposure to carotenoids (a biologic marker of intake of
deeply colored vegetables and fruits) was found to be associated with longer recurrence-free survival, regardless of study
group, suggesting that vegetable and fruit intake prior to
the diagnosis of breast cancer may improve prognosis.137
Vegetables can reduce the total energy density in the diet,
and both vegetables and fiber are associated with improved
satiety. Data on breast cancer survivors participating in the
Nurses Health Study, who were followed for a mean period
of nearly 10 years postdiagnosis, suggest that those who
consume a healthy diet, with higher intakes of fruits,
vegetables, and whole grains and lower intakes of added
sugar, refined grains, and animal products, may not have
had significantly lower rates of recurrence or cancer-specific
mortality, although women who report this eating pattern
have significantly lower rates of mortality from other
diseases, such as heart disease, when compared with those
who eat typical Western diets.120
Soy foods and flaxseed are both rich sources of phytoestrogens, biologically active compounds called isoflavones that
can exhibit both antiestrogenic and estrogen-like properties.
High circulating estrogen levels are a documented risk factor
for breast cancer recurrence.207 Because soy isoflavones have
been shown to promote in vitro growth of breast cancer cells
and mammary tumor growth in laboratory animals, there has
been some concern about the potential adverse effect of soy
consumption on prognosis in women who have been diagnosed with breast cancer. However, 3 large epidemiological
studies in the recent past have found no adverse effects of soy
food intake on breast cancer recurrence or total mortality
either alone or in combination with tamoxifen, and there is
the potential for these foods to exert a positive synergistic
effect with tamoxifen.208-210 Two of these studies were
focused on US samples and included isoflavone supplements
in the data collection and analysis. Current evidence does not
suggest that consuming soy foods is likely to have adverse
effects on risk of recurrence or survival. Isoflavone supplement use was uncommon in the populations in these recent
cohort studies, and therefore the evidence relating to the
effects of these supplements is more limited.
Alcohol intake has been linked with an increase in the
risk of primary breast cancer170; however, among cancer
survivors, associations have been mixed, with protective
effects found between alcohol intake and risk of subsequent
ovarian cancer in one study,174 increased risk of contralateral disease and recurrence and death found in 2 other
studies,176,177 and one study that showed neither risk nor
protection for breast cancer recurrence with low to
moderate alcohol intake.175 The discrepancy noted with

regard to alcohol and overall survival may be due in part to
the fact that alcohol intake is associated with a reduced risk
of cardiovascular disease, a common comorbidity among
breast cancer survivors, and also is usually inversely associated with obesity. Theoretically, however, alcohol intake
could affect the risk of a second primary breast cancer, for
which all breast cancer survivors are at increased risk. Alcohol is an unusual factor, however, because it presents both
risks and benefits. In the general population, clear and consistent evidence links moderate alcohol intake (1-2 drinks
per day) with a lower risk of cardiovascular disease.166 For
breast cancer survivors, the decision to drink alcoholic
beverages at moderate levels is complex because they must
consider their levels of risk for recurrent or second primary
breast cancer as well as cardiovascular disease.
It is important to remember that nutrition and physical
activity recommendations to reduce the risks of a second
primary breast cancer and heart disease are especially
important for breast cancer survivors.49,52,211,212 Diets
should emphasize vegetables and fruits, have low amounts
of saturated fats, and include sufficient dietary fiber.124
Most importantly, breast cancer survivors should strive to
achieve and maintain a healthy weight through eating a
well-balanced diet and regular exercise.136 In addition,
regular physical activity should be maintained regardless of
any weight concerns.
Colorectal Cancer
Epidemiologic, clinical, and laboratory research indicates
that diet, adiposity, and physical activity have a significant
influence on the risk of developing colorectal cancer.213,214
Over the past decade, there has been an increasing number
of studies that have examined the influence of these modifiable host factors on physical well-being, quality of life, and
cancer recurrences and survival.78
Several observational studies have shown that higher
physical activity levels or meeting physical activity guidelines
is associated with better patient-reported quality of life,
physical functioning, and fatigue.215-220 One randomized
trial of an exercise intervention in colorectal cancer survivors
demonstrated that participants whose aerobic fitness
increased over the course of the intervention, regardless of
group assignment, reported significantly improved quality
of life, physical functioning, and psychosocial distress
compared with participants whose fitness decreased.221
Recently emerging, prospective, observational data have
shown that colorectal cancer survivors who are physically
active lower their risk of cancer recurrence, colorectal
cancer-specific mortality, and/or overall mortality.104-107,222
These data have led to the initiation of the Colon Health
and Life-Long Exercise Change (CHALLENGE) trial,
a randomized, controlled, multinational collaboration

between Canada and Australia to determine the effects of a
3-year structured physical activity intervention on disease
outcomes in survivors of high-risk stage II and III colon
cancer who have completed adjuvant chemotherapy within
the previous 2 to 6 months.108
The impact of obesity on outcomes in colorectal cancer
survival has been less certain.89,223-225 Most prospective
observational cohort studies have used a single measurement of weight and height at the time of diagnosis and
have primarily demonstrated that only class II and III
obesity (BMI 35 mg/m2) may modestly worsen outcomes
(approximately 20% worse disease-free survival).89,225 A
recent study from the ACS Cancer Prevention Study II
Nutrition Cohort reported that an obese BMI before the
diagnosis of colorectal cancer (mean, 7 years prior to
diagnosis) was associated with higher risks of death from
all causes, colorectal cancer-specific causes, and cardiovascular disease, while the BMI reported after a diagnosis
of colorectal cancer was not associated with any of the
mortality outcomes.226
Although diet has been extensively studied as a risk factor for developing colorectal cancer, there are very limited
data concerning diet in colorectal cancer survivors as related
to survival outcomes. The largest prospective study to date
included survivors of stage III colon cancer and demonstrated that a Western dietary pattern, resulted in a worse
disease-free and overall survival.123 In contrast, a diet
characterized by high intakes of fruits and vegetables, poultry, and fish was not significantly associated with cancer
recurrence or mortality. Vitamin D status has been shown
fairly consistently to influence the risk of developing
colorectal cancer.227 Emerging data suggest that vitamin D
status may influence outcomes in colorectal cancer survivors
as well and this is an active area of research as both a
secondary preventive and treatment strategy in colorectal
cancer.156,157
Because most colorectal cancers arise from adenomatous
polyps, the prevention of polyp recurrence has also been a
focus of considerable clinical research. To date, trials have
failed to show benefits in preventing new polyp growth
during a 3-year or 4-year period from antioxidant vitamins,
fiber supplements, or modest dietary changes to increase
fruit and vegetable intake.228 Folate has not been shown to
reduce polyp recurrence in clinical trials229,230 and was
associated with an increased risk of having multiple
adenomas.230 Calcium supplements, however, provided a
modest benefit in preventing polyp recurrence.231
Colorectal cancer survivors should be advised to maintain
a healthy weight, participate in regular physical activity,
and eat a well-balanced diet consistent with guidelines for
cancer and heart disease prevention. Colorectal cancer
survivors with chronic bowel problems or surgery that
257
affects normal nutrient absorption should be referred to a

registered dietitian to modify their diets to accommodate
these changes and maintain optimal health.
Endometrial Cancer
Endometrial cancer is the most common gynecologic cancer
and the fourth most common cancer in women.4 The
prognosis of endometrial cancer is related to the stage of
disease at diagnosis, with a 90% survival rate if diagnosed at
stage I,232 which is common because the main symptom,
abnormal bleeding, is easy to detect and likely to cause
women to seek medical attention.
Obesity is a strong risk factor for the development of
endometrial cancer. Approximately 70% to 90% of women
with type 1 endometrial cancer (the most common type) are
obese.233 However, there are few studies of the role of
obesity in endometrial cancer prognosis. Prediagnosis
obesity has been shown to be associated with a significant
increase in endometrial cancer mortality.234 This may be
related to common comorbidities among obese women,
such as type 2 diabetes and hypertension, which may
complicate cancer treatment.76 In a study using data from
participants in a Gynecologic Oncology Group trial of early
stage endometrial cancer, obesity was associated with
higher mortality from causes other than endometrial cancer
but not with recurrence.235 Obese women tend to develop
less aggressive endometrial cancer236-238; however, decreased
overall survival among obese endometrial cancer patients has
been seen in some studies,235,239 but not in others.236-238
No studies have reported on the role of dietary factors
and physical activity in the prognosis of endometrial
cancer. Although the role of obesity in endometrial cancer
prognosis is not completely understood, studies have shown
that a higher BMI and a sedentary lifestyle are associated
with a poorer quality of life among endometrial cancer
survivors.233,240,241
Ovarian Cancer
Ovarian cancer is the leading cause of death from gynecologic
malignancies in the United States.4 Symptoms tend be
nonspecific, making early detection difficult. Consequently,
most ovarian cancers are diagnosed at an advanced stage
when the prognosis is poor, with an overall 10-year survival
rate of 39%.4 The role of lifestyle factors in ovarian cancer
prognosis is largely unknown.138,242 To our knowledge, only
3 studies139,140,243 have evaluated the role of dietary factors
in ovarian cancer survival. These 3 studies were based on prospective follow-up of the cases participating in case-control
studies and evaluated the association between prediagnosis
dietary intake and mortality outcomes. One study, conducted
in China, focused on the role of green tea and reported that a
higher frequency and quantity of green tea intake after
258
diagnosis was associated with better survival.243 The other 2

studies, conducted in Australia140 and the United States,139
suggested that prediagnosis dietary intake may influence the
survival experience of patients with ovarian cancer. Both
studies tended to support the association of fruit and
vegetable consumption with better survival. Dairy food
intake was associated with poorer survival in one of the
studies,140 while in the other, only milk consumption and
not total dairy food consumption was inversely associated
with survival.139 Meat consumption was associated with
better survival in the Australian study,140 and with lower
survival in the study conducted in the United States.139
While these studies controlled for most relevant covariates,
they did not include treatment information. In addition,
these studies did not evaluate dietary intake after diagnosis.
However, they do suggest that dietary intake may influence
ovarian cancer survival and warrant further research in this
area.
Only one study, also following cases in a case-control
study for mortality, has evaluated the role of physical
activity in ovarian cancer survival.244 Prediagnosis
physical activity was ascertained as hours per week for 3 life
periods (childhood, between ages 18-30 years, and in recent
years). The study also evaluated the role of changes in physical activity over time. There was not much indication of an
association with survival for any of these variables, except
for physical activity at aged 18 to 30 years, which seemed to
be associated with better survival for women with early
stage ovarian cancer and with worse survival for women
with an advanced stage of disease at diagnosis.245
The relationship between excess weight and ovarian
cancer survival has been evaluated by relatively few studies.
Obesity may affect ovarian cancer survival by having a negative impact on optimal surgical and cytotoxic treatment
and increasing the likelihood of postoperative complications.246 Overall, the literature evaluating the association
between weight/BMI and ovarian cancer survival is limited
and inconclusive.76,242 Cohort studies evaluating the role of
prediagnosis obesity obtained at baseline on ovarian cancer
mortality have generally found elevated ovarian cancer
mortality among obese women.234,247 Other studies
evaluating the role of prediagnosis BMI on ovarian cancer
survival by following cases in a case-control study or clinical
trial (using baseline data) have offered conflicting results.242
The role of postdiagnosis body size and weight changes on
ovarian cancer survival is largely unknown. Only one study
has reported on weight changes during chemotherapy and
ovarian cancer survival and found that, among patients with
advanced ovarian cancer, weight loss during chemotherapy
was associated with worse prognosis; however, it is difficult
to determine whether this weight loss was involuntary
or intentional.248
In summary, while the current evidence is limited and

inconclusive, it points to a possible role of dietary factors,
physical activity, and body size and weight changes in
modulating ovarian cancer survival, and for physical activity
in improving the quality of life among ovarian cancer
survivors. Further studies are needed before public health
recommendations can be made.
Hematologic Cancers and Cancers Treated With

Hematopoietic Stem Cell Transplantation
A possible relationship between dietary factors and outcomes
of hematologic cancers has been examined in only a few
studies to date.
Overweight or obesity appears to adversely affect prognosis
for patients who undergo hematopoietic stem cell transplantation, although the evidence is limited. In a study that
focused on clinical data from patients who underwent
autologous stem cell transplantation, obesity had significant
adverse effects on treatment-related toxicity and mortality,
overall survival, and disease-free survival.249
Observational research has shown that the physical
activity levels of survivors of hematological cancer are low,
with deleterious health consequences. Multiple intervention studies have tested the benefit of exercise in both adult
and pediatric survivors of hematological cancer.30,250,251
Systematic reviews of adult interventions have reported
that physical activity can improve body composition,
cardiorespiratory fitness, fatigue, muscle strength, physical
functioning, and quality of life.250
The conditioning regimen of intensive chemotherapy,
often in conjunction with total body irradiation, is associated with several specific side effects that have significant
adverse nutritional consequences such as nausea, vomiting,
diarrhea, oropharyngeal mucositis, and esophagitis. Total
body irradiation damages the gastrointestinal mucosa, resulting in malabsorption and diarrhea because these epithelial
cells are highly susceptible to the effects of radiation.
Nutritional problems also result from adverse effects of various drug therapies, such as oral immunosuppressive agents
and antibiotics that may be necessary for posttransplant
management. Finally, the common complication of graft
versus host disease (in patients who receive an allogeneic
transplant) results in abdominal pain, nausea, severe diarrhea,
malabsorption, and substantial nitrogen losses. Patients who
do not receive specialized nutritional support typically eat
poorly for a prolonged period and are at high risk of poor
nutritional status.252-254
As an infection prevention strategy, low-microbial diets
are often prescribed for transplant recipients. A low-microbial
or low-bacteria diet is primarily a cooked-food diet, because
the major limitation imposed is on fresh or uncooked food
items.255 Because many food restrictions are imposed with
this strategy, the nutrient adequacy of the actual food intake

of patients who are prescribed the low-microbial diet should
be monitored. Prevention of malnutrition and correction of
energy and nutrient inadequacies has been incorporated into
the standardized posttransplant treatment at most transplant
centers. In a recent review of the evidence regarding the
relative effectiveness of enteral nutrition versus parenteral
nutrition support, the issue could not be evaluated due to a
lack of evaluable data.256 Recent trends include prescribing
less parenteral nutrition support and more enteral nutrition
support,255 which could reduce the risk of medical complications
and control costs.
Lung Cancer
Lung cancer treatment is often aggressive and causes
adverse effects. Furthermore, many lung cancer survivors
are underweight and have low blood nutrient levels
even before diagnosis as a result of the adverse effects of
inadequate diets, smoking, or both on micronutrient status.
During treatment and the immediate recovery period, lung
cancer survivors may benefit from eating foods that are
energy-dense and easy to swallow. Small, frequent meals
may be easier to manage than 3 large meals per day.
Medications and nutritional support via energy-dense nutritional supplements or enteral nutrition may be helpful for
those experiencing weight loss.257 If nutrient deficiencies are
present or survivors cannot eat enough to adequately meet
micronutrient needs, a multivitamin-mineral supplement is
advisable, either in pill or liquid form.
Patients with lung cancer present with a complex variety
of symptoms that can limit physical function and lead to
distress, including dyspnea, air hunger, anxiety, muscle
weakness, fatigue, and limited cardiopulmonary function.
Despite these issues, there have been several clinical trials
that have successfully demonstrated the feasibility of
exercise interventions in select lung cancer patients. A
recent systematic review of 16 studies inclusive of 675 lung
cancer patients demonstrated that patients participating in
an exercise intervention prior to surgery reported improvements in exercise capacity but no change in health-related
quality of life immediately after the intervention.258
Furthermore, other studies of exercise following standard
lung cancer treatment demonstrated improvements in
exercise capacity but had conflicting results with respect to
the impact on quality of life. More research is needed in
this cancer patient population.
The possible effect (either beneficial or harmful) of
nutritional supplements other than beta-carotene after the
diagnosis of lung cancer has not been extensively studied.
One clinical trial of selenium and skin cancer noted a
reduced incidence of lung cancer in association with
selenium supplementation.259 While some researchers have
259
found that individuals with early stage lung cancer who

have better vitamin D status have improved survival,260
these findings need replication.
Few studies have examined the relation between dietary
factors and lung cancer prognosis. Two small studies sought
to determine whether dietary intervention with selected
vegetables improved survival among those with advanced
lung cancer.261,262 Weight loss was less and survival was
longer in the intervention groups in those studies, but these
preliminary findings need to be confirmed by larger studies.
Three randomized clinical trials that included lung cancer
survivors, among others, encouraged participants to
increase their energy intake.263-265 Although successful in
increasing energy intake, none of the strategies used within
these studies prevented weight loss.
Recommendations for nutrition and physical activity for
individuals who are living with lung cancer are best made
based on individual needs. Striving toward a healthy weight
by adjusting food intake and physical activity is a reasonable
goal, as is ensuring that nutritional needs are met with a
nutritious diet and a multivitamin-mineral supplement, if
needed, to achieve adequate levels of intake.
Prostate Cancer
Most research on nutrition and prostate cancer has focused
on prostate cancer incidence.266,267 Because asymptomatic
prostate cancer is very common in older men, the same
lifestyle factors that are associated with a reduced prostate
cancer incidence might also reduce the rate of prostate cancer growth after diagnosis, thus preventing or slowing the
progression of early stage prostate cancer. However, notable
exceptions are body weight and obesity, which appear to
be related to cancer progression and the more aggressive
forms of prostate cancer, and not the latent or indolent
disease that appears to be an artifact of aging.268 In recent
years, a few studies have tried to determine directly whether
such dietary factors may prolong survival from prostate
cancer or may influence biomarkers (eg, prostate-specific
antigen [PSA] levels) that are associated with outcomes for
men with prostate cancer.
A high intake of foods from animal sources, especially
foods high in saturated fat, has been associated with an
increased risk of prostate cancer.203,266 Whether this
increased risk is due to saturated fat per se or to the consumption of red meat and high-fat dairy products is
unclear. The observation that fatty fish intake may decrease
prostate cancer mortality rates suggests that, if fat is
important, the type of fat may play a key role. There are 2
follow-up studies of dietary factors and survival in prostate
cancer survivors. One found that saturated fat intake (but
not total fat) is associated with worse survival,269 and the
other found that monounsaturated fat intake is associated
260
with better survival.129 Based on what we currently know

and on the role of saturated fat in cardiovascular disease
and its potential role in prostate and colon cancer incidence,
decreasing saturated fat intake is likely very beneficial in
this population.47,49 Recently, a secondary analysis of a trial
of prostate cancer patients found that those who were
assigned to the low-fat diet had significantly decreased
blood levels of inflammatory markers that are linked to
cancer progression.270 Similar to the WINS study,
however, it is unknown whether this response was due
more to dietary fat restriction or to weight loss.
In one study in which the relationship between dietary
intakes and risk of prostate cancer recurrence was examined,
intakes of fish and tomato sauce were observed to be
associated with reduced risk.141 Although benefits to prostate
cancer risk and progression from vegetables and fruits are far
from certain, a diet high in these foods has been found to
reduce the risk of cardiovascular diseases.49 Therefore, it is
probably beneficial for prostate cancer survivors to eat plenty
of micronutrient- and phytochemical-rich vegetables and
fruits.
Increased consumption of soy foods (eg, tofu and soy
milk) is a common self-care strategy among prostate cancer
survivors, under the assumption that the phytoestrogens may
be beneficial. Although some studies suggest that soy foods
may decrease the risk of prostate cancer, no rigorous studies
have been reported that examined the effects of soy or other
phytoestrogens on the progression of prostate cancer after
diagnosis. In a randomized controlled trial of 161 men, those
assigned to consume 30 g of ground flaxseed per day
(a concentrated source of lignans, as well as omega-3 fatty
acids) were found to have significantly lower prostate tumor
proliferation rates compared with the control group.271
Prostate cancer survivors undergoing androgen deprivation
therapy (ADT) are at a high risk of osteoporosis. In addition, a recent study indicated that low 25-hydroxyvitamin
D (25(OH)D) levels (the major form of vitamin D in the
circulation) were associated with lethal prostate cancer.272
It is not known if calcium or vitamin D supplements would
be useful or detrimental in these cases, since high amounts
of calcium, particularly through supplements, have been
linked to more aggressive disease.273 It would seem prudent
for men to adopt a diet that provides at least 600 IU of
vitamin D per day and to consume adequate, but not
excessive, amounts of calcium (ie, exceeding 1200 mg/day),
as well as to pursue active lifestyles that include routine
weight-bearing exercises. The role of vitamin D and related
compounds in the prevention of prostate cancer recurrence
is currently being studied; 2 preliminary studies suggest
that vitamin D, administered either separately or in
conjunction with chemotherapy, may reduce PSA levels,
although further research is needed to determine the longer
term effects of vitamin D supplementation.274,275
Vitamin E supplementation in a large prevention trial

intended to affect lung cancer was shown to be associated
with a reduced risk of prostate cancer, but vitamin E had no
effect on survival in the men in whom prostate cancer developed in that study,276,277 and results from a recently published
randomized controlled trial indicated that men randomized to
receive vitamin E were at a slightly greater risk of developing
prostate cancer.153,278 Likewise, although selenium supplements
reduced prostate cancer incidence in a small trial intended to
prevent skin cancers,259,279 the same recently published trial
(SELECT) found no protection from selenium in prostate
cancer, and it actually predisposed men to diabetes.278
Two large cohort studies have found that obese men are
at a much greater risk of prostate cancer mortality and prostate cancer specific mortality following diagnosis.234,280
Moreover, in a single-institution study, Freedland et al
found that obesity was associated with a higher risk of biochemical failure in men treated with radical prostatectomy,56
and in another single-surgeon prostatectomy cohort, men
who gained weight after diagnosis had almost twice the risk
of recurrence (most being cases of biochemical failure) compared with men who maintained their weight after taking
into account other prognostic factors. In this latter study,
men who lost weight also appeared to have a lower risk of
recurrence, although this observation was not statistically
significant.281
Many prostate cancer survivors are confronted with profound
changes in body composition related to ADT, including bone
loss, muscle loss, and fat gain. These changes lead to significant
deconditioning, muscle weakness, fatigue, and depression.
Multiple trials have tested the impact of exercise, particularly
resistance training, at different stages of the spectrum of
treatment in men with prostate cancer. A systematic review
of 9 studies on the effects of exercise on health outcomes
demonstrated promising effects of physical activity on muscular fitness, physical functioning, fatigue, and health-related
quality of life.282 A recent randomized trial of 121 prostate
cancer patients initiating radiation therapy with or without
ADT randomly assigned to usual care, resistance training, or
aerobic exercise demonstrated that resistance training
improved short- and long-term fatigue, quality of life, aerobic fitness, and upper and lower body strength, and prevented
an increase in body fat.283 Aerobic exercise improved shortterm fatigue and fitness.
Recently, a prospective observational cohort of over 2700
men with nonmetastatic prostate cancer found that physically
active men had significant improvements in all-cause and
prostate cancer-specific mortality.65 Men who engaged in
at least 3 hours per week of vigorous activity had a nearly
50% reduction in all-cause mortality and a 60% reduction in
prostate cancer-specific deaths.
Men in whom prostate cancer has been diagnosed should
strive to achieve and maintain a healthy weight, pursue a
physically active lifestyle, and consume a diet that is rich in
vegetables and fruits and low in saturated fat, with reliance

on dietary sources of calcium that are within moderate
levels. Such dietary suggestions, however, need to be considered within the context of an increased risk of fractures
from antiandrogen therapy and physical activity patterns.
Although the evidence relating these recommendations to
prostate cancer recurrence is limited, there are likely
substantial other benefits, most prominently decreasing
cardiovascular disease risk, which is the major cause of
death in prostate cancer survivors.
Upper Gastrointestinal and Head and

Neck Cancers
Few studies have considered whether dietary factors or
physical activity influence prognosis in survivors with upper
gastrointestinal or head and neck cancers. A clinical trial of
the effects of a beta-carotene supplement (vs placebo)
among survivors with head and neck cancers found that
those administered beta-carotene had rates of cancer recurrence or survival that were similar to those in the control
group.284 In contrast, a clinical trial of vitamin E found an
increased risk of recurrence compared with a placebo in this
same patient population.152
Head and neck cancers can directly compromise food
intake, and a high percentage of patients have lost weight
or are malnourished at the time of diagnosis. Comprehensive care of these survivors includes appropriate nutritional
assessment and support, and physical activity and physical
therapy to improve overall health before, during, and after
treatment. Poor nutrient intake can stem from difficulties
in biting, chewing, and swallowing at diagnosis or after surgery and from xerostomia, mucositis, and taste alterations
resulting from radiation therapy or concurrent chemoradiation therapy. Many long-term survivors of head and neck
cancers will experience at least some degree of aspiration
associated with substantial weight loss, diminished swallowing efficiency, and lower quality-of-life scores.285 During
and immediately after treatment, the texture, temperature,
consistency, nutrient content, and frequency of oral feedings
often need to be modified. Acidic, salty, or spicy foods and
foods at extreme temperatures may not be well tolerated.
Sugar-free gums and mints as well as the use of commercial
oral rinses and gels and the consumption of water may
provide limited relief of symptoms and enhance appetite.
Pureed or blenderized foods may be better tolerated during
treatment and recovery. Chemoradiation may have a significant effect on a patients ability to eat, which should
improve by 12 months after treatment.286 Health care
providers may offer alternate approaches to meeting nutrient
requirements if eating and drinking by mouth cannot
support these needs. Gastrostomy tubes are commonly
placed prophylactically to support the patient through
261
treatment and the period of time immediately after treatment. Patients are encouraged to eat soft, moist foods
throughout treatment to maintain their swallowing function. Patients with esophageal and gastric cancers may need
support through treatment as well. This population may
require placement of either a gastrostomy tube or a jejunostomy tube, depending on anticipated or performed surgical
interventions. When tube feeding is started immediately after surgery for esophageal or gastric cancer, it may reduce
both the duration of intensive care unit treatment and total
hospital stay.286,287
Several small studies have shown that physical activity
may improve functioning, reduce pain and disability, and be
related to quality of life in head and neck cancer survivors.288-290 One study of 52 head and neck cancer survivors
that compared progressive resistance exercise with standard
physical therapy demonstrated that resistance training significantly improved self-reported shoulder pain and disability,
upper extremity strength, and upper extremity endurance.289
Furthermore, changes in neck dissection impairment, fatigue,
and quality of life nonsignificantly favored those patients
treated with resistance training.
Patients with esophageal or gastric cancer may have
symptoms such as early satiety, dumping syndrome, or
malabsorption that affect food and nutrient intake, as well
as absorption and digestion; the effects of treatment may
result in long-term or permanent nutritional complications.
Survivors with esophageal cancer can experience temporary
or long-term dysphagia, odynophagia, gastroesophageal
reflux, and early satiety.9 Diet modifications determined
with the assistance of an oncology-certified registered
dietitian can help to manage some of these treatmentrelated conditions, help regain or maintain a healthy
weight, and restore some quality of life.
The nutritional management of patients with gastric cancer
is based on determining the portion of the stomach involved
with disease or the condition after surgical resection. If
either the esophageal or pyloric sphincter has been affected,
diet modifications will involve small, more frequent meals/
snacks, no concentrated sweets, and the consumption of
fluids between meals due to early satiety. In addition, the
patient is advised to stop eating 3 hours before bedtime or
going to bed to avoid aspiration. There is a significant risk
of micronutrient deficiencies in this patient population due
to the alteration of the digestion process and absorption of
minerals such as iron and calcium and vitamins such as
vitamin B12. If possible, a patients status should be tested
pretreatment and followed through the treatment and
long-term survivorship period.
In the case of pancreatic cancer, there is increasing
evidence that supplementation with omega-3 fatty
acids has a favorable effect on short-term weight status,
262
performance status, or related factors.291-294 Weight loss is

common at diagnosis in this population, and these patients
often experience profound exocrine dysfunction, in addition
to endocrine dysfunction, throughout the course of their
cancer treatment. Pancreatic enzymes can be very helpful,
along with diet modification, to manage disease symptoms
and treatment side effects. Consultation and close follow-up
with a registered dietitian for an individualized dietary
prescription is recommended.
In the absence of more definitive information, survivors
of head and neck and upper gastrointestinal cancers should
follow, to the extent they are able, the ACS nutrition and
physical activity guidelines for the prevention of cancer.52
Common Questions About Diet, Physical

Activity, and Cancer Survivorship
Cancer survivors often request information and advice from
their health care providers about food choices, physical
activity, and dietary supplement use to improve their quality of life and survival. Health professionals who counsel
patients should emphasize that no one study provides the
last word on any subject, and that individual news reports
may overemphasize what seem to be contradictory or
conflicting results because they appear to be new or different or challenge conventional wisdom. In brief news stories,
reporters cannot always put new research findings in their
proper context. The best advice about diet and physical
activity is that it is rarely advisable to change diet or activity
levels based on a single study or news report. The following
questions and answers address common concerns of cancer
survivors regarding diet and physical activity.
Alcohol
Does Alcohol Increase the Risk of Cancer Recurrence?
Many studies have found a link between alcohol intake and
risk of some primary cancers, including cancers of the mouth,
pharynx, larynx, esophagus, liver, breast, and probably colon
cancer.47,170,165 In individuals who have already received a
diagnosis of cancer, alcohol intake could also affect the
risk of new primary cancers of these sites.171 Alcohol intake
can increase the circulating levels of estrogens, which
theoretically could increase the risk of a recurrence of
ER-positive breast cancer; currently, however, only a few
studies have explored alcohol use among breast cancer
survivors, with approximately one-half showing a detrimental
effect and one-half showing benefit or no harm. One study
suggests that the detrimental effects of alcohol may be
exacerbated in women who are overweight or obese.176
Given that alcohol does exert cardioprotective effects, the
question of whether to consume it or not depends heavily
upon hereditary disposition and risk of recurrence versus
risk of cardiovascular disease.
Should Alcohol Be Avoided During Cancer Treatment?

The cancer type and stage of disease, as well as treatment,
should be considered when making recommendations on
alcohol use during treatment. Many chemotherapeutic
agents are metabolized in the liver, and inflammation of
the liver from alcohol, particularly around the time of treatments, may affect the clearance of chemotherapeutic drugs
and worsen toxicities. It is generally advised to avoid or
keep consumption to a minimum to prevent interaction
with chemotherapeutic drugs, and to avoid further aggravation to treatment areas during radiation therapy. Alcohol,
even in the small amounts found in mouthwashes, can be
irritating to survivors with oral mucositis, can exacerbate
that condition, and can compromise healing.295
Antioxidants
What Do Antioxidants Have to Do With Cancer?
Antioxidants exist naturally in many forms and help prevent
oxidative damage to tissues. Because oxidative damage may
be important in the development of cancer, it has been
hypothesized that increasing intake of antioxidants from
foods or supplements may help prevent cancer. Some
studies suggest that people who eat more vegetables and
fruits, which are rich sources of antioxidants (including
vitamin C, vitamin E, carotenoids, and many other antioxidant phytochemicals), may have a lower risk of some
types of cancer.296 Because cancer survivors are at an
increased risk of second cancers,45 they should be encouraged to consume a variety of these antioxidant-rich foods
each day. However, clinical studies of antioxidant dietary
supplements have not demonstrated a reduction in cancer
incidence.297,298 The best advice presently is to obtain
antioxidants through food or beverage sources rather than
dietary supplements.
Is It Safe to Take Antioxidant Supplements
During Cancer Treatment?
Many dietary supplements contain levels of antioxidants
(such as vitamins C and E) that substantially exceed the
amount recommended in the Dietary Reference Intakes
for optimal health.17,21,299 At the present time, evidence is
limited, but taking high doses of supplements with antioxidant activity during chemotherapy or radiation therapy may
be unwise because antioxidants could potentially repair the
cellular oxidative damage to cancer cells that contributes
to the effectiveness of these treatments.300,301 Others,
however, have noted that the possible harm from antioxidants is only hypothetical and that there may be a net
benefit to help protect normal cells from the collateral damage associated with these therapies.23 Whether antioxidants
or any other dietary supplements specifically are beneficial or
harmful during chemotherapy or radiation therapy is a question without a clear scientific answer at this time.22,302-304
Given this uncertainty, until more evidence is available that

suggests more benefit than harm, it is prudent for cancer
survivors currently receiving chemotherapy or radiation
therapy to limit the usage of supplements to nutrients for
which a deficiency has been demonstrated, and avoid dietary
supplements exceeding 100% of the Daily Value for antioxidant vitamins, unless specifically recommended by a
physician for the treatment of a specific condition.17,20,21
Fat
Will Eating Less Total Fat, or Less of Certain Types
of Fat, Lower the Risk of Cancer Recurrence or
Improve Survival?
Several studies have been conducted on the relationship
between fat intake and survival after the diagnosis of breast
cancer, with inconsistent results.136 Preliminary results
from a large clinical trial of early stage breast cancer
survivors suggest that low-fat diets may reduce the risk
of recurrence, particularly in women with ER-negative
disease.91 It is important to note that although there is not
conclusive evidence that total fat consumption influences cancer outcomes, diets very high in fat tend to be high in calories
and may contribute to obesity, which in turn is associated
with an increased cancer incidence at several sites, an
increased risk of recurrence, and a reduced likelihood of
survival for many cancer sites (see Obesity).
There is evidence that certain types of fat, such as
saturated fats, may have an effect on increasing cancer
risk.47,48,305 There is little evidence that other types of fat
(omega-3 fatty acids, found primarily in fish and also
walnuts; monounsaturated fatty acids, found in olive and
canola oils; or other polyunsaturated fats) reduce cancer risk.
In one study, saturated fat intake was inversely associated
with prostate cancer-specific survival and in another, monounsaturated fat intake and risk of death from prostate cancer
were inversely associated.129,130 In addition, excess saturated
fat intake is a known risk factor for cardiovascular diseases,
which are a major cause of morbidity and mortality in all
populations, including cancer survivors. Although trans fats
have adverse cardiovascular effects, such as raising blood
cholesterol levels,49,306 their relationship to cancer incidence
or survival has not been observed. Regardless, due to the relationship with increased cardiovascular disease risk, survivors
should consume as few trans fats as possible. Major sources
of trans fats are some margarines, baked goods, and snack
foods that contain partially hydrogenated oils.
Fiber
Can Dietary Fiber Prevent Cancer or Improve
Cancer Survival?
Dietary fiber includes a wide variety of plant carbohydrates
that are not digestible by humans. Specific categories of
fiber are soluble (such as oat bran) or insoluble (such as
263
wheat bran and cellulose). Soluble fiber helps lower the risk
of coronary heart disease by reducing blood cholesterol
levels. Fiber is also associated with improved bowel function.
Good sources of fiber are beans, vegetables, whole grains,
nuts, and fruits. Consumption of these foods is recommended because they contain other nutrients that may help
reduce cancer risk and provide other health benefits, such as
a reduced risk of coronary heart disease.46
discourage the practice of cooking these and other higher fat

sources of protein at high temperatures. This recommendation may also be applied to cancer survivors for the promotion of general good health, although currently, there is no
evidence available regarding the effect of processed meat,
meat cooked at high temperatures, or meat in general on
cancer recurrence or progression.
Flaxseed
Obesity
Flaxseed is an excellent source of vitamins, minerals, and

fiber, and also is an exceedingly rich source of phytoestrogenic lignans and omega-3 fatty acids.307 While further
work in humans is necessary, cell culture and animal studies
suggest that flaxseed or its isolated compounds reduces
tumor growth and also may potentiate the effects of some
treatments, such as tamoxifen. Two randomized controlled
clinical trials in cancer survivors, one conducted in 32
women with breast cancer and another performed in 161
men with prostate cancer, showed that patients who were
assigned to flaxseed-supplemented diets prior to cancer
surgery had significantly lower tumor proliferation rates
than those who were assigned to other diets.271,308 More
research, however, is needed to corroborate these findings.
Does Being Overweight Increase the Risk of Cancer

Recurrence and Second Primary Cancers?
Increasing evidence indicates that being overweight or obese
increases the risk of recurrence and reduces the likelihood of
survival for many cancers.63,76 Overweight and obesity are
also associated with increased death rates for all cancers
combined.55,234 Because of other proven health benefits
to losing weight, people who are overweight should be
encouraged to achieve and maintain a healthy weight. The
avoidance of excessive weight gain during adulthood is
important not only to reduce cancer incidence and risk of
recurrence, but the risk of other chronic diseases as well.49,51,52
Food Safety
Are Foods Labeled Organic Recommended for

Cancer Survivors?
Are There Special Food Safety Precautions for

Individuals Undergoing Cancer Treatment?
Infection is of special concern for cancer survivors, especially
during episodes of immunosuppression and leukopenia that
can occur with certain cancer treatment regimens.178 During
immunosuppressive cancer treatment, survivors should be
particularly careful to avoid eating foods that may contain
unsafe levels of pathogenic microorganisms. General food
safety practices, such as washing hands before eating,
thoroughly washing vegetables and fruits, and keeping foods
at proper temperatures, should be encouraged, and survivors
should receive specific guidance regarding food safety, as
outlined in Table 5.
Meat: Cooking and Preserving
Should I Avoid Meats?
Several epidemiologic studies have linked high consumption
of red and processed meats with an increased risk of
colorectal, prostate, and stomach cancers.305,309-311 Some
research suggests that frying, broiling, or grilling meats,
particularly meats that are higher in fat and poultry with
skin, at very high temperatures creates chemicals called
heterocyclic amines that have been shown to be carcinogenic. For these reasons, the ACS guidelines on nutrition
and physical activity for cancer prevention recommend
limiting the consumption of processed and red meats and
264
Organic Foods
The term organic is used to describe foods grown without

pesticides and genetic modifications or meat, poultry, eggs,
and dairy products obtained from animals that are given no
antibiotics or growth hormones. The use of the term
organic on food labels and packaging is regulated by the US
Department of Agriculture to meet these and other criteria. It
has been suggested that organic foods may be more healthful
because they reduce exposure to agricultural chemicals. It has
also been suggested that their nutrient composition may be
better than that of their conventionally grown counterparts.
Whether this translates into health benefits from the consumption of organic foods is unknown. At present, no epidemiologic
studies in humans exist to demonstrate whether such foods
are more effective in reducing cancer incidence, recurrence,
or progression than similar foods produced by other farming
and production methods.
Physical Activity
Should I Exercise During Cancer Treatment
and Recovery?
Evidence strongly suggests not only that exercise is safe and
feasible during cancer treatment, but also that it
can improve physical functioning and various aspects of
quality of life. Moderate exercise has been shown to
improve fatigue, anxiety, and self-esteem as well as cardiovascular fitness, muscle strength, and body composition.
Patients receiving chemotherapy and radiation therapy who

already exercise may need to temporarily do so at a lower
intensity and/or shorter duration compared with individuals who are not receiving cancer treatment. The principal
goal should be to maintain activity as much as possible and
increase levels after treatment has been completed.
Are There Special Precautions Survivors
Should Consider?
Particular issues for cancer survivors may affect or contraindicate their ability to exercise. Some effects of treatment
may also increase the risk of exercise-related injuries and
adverse effects. For example, survivors with severe anemia
should delay activity until the anemia is improved, survivors
with compromised immune function should avoid gyms
and other public places until their white blood cell counts
return to safe levels, and survivors undergoing radiation
should avoid swimming pools because chlorine exposure
may irritate irradiated skin. For those individuals who were
sedentary before diagnosis, light-intensity activities should
be adopted and slowly advanced. For older persons and
those with bone disease (due to skeletal metastases or to
severe osteoporosis) or significant impairments such as
arthritis or peripheral neuropathy, careful attention should
be given to balance to reduce the risk of falls and injuries.
Can Regular Exercise Reduce the Risk
of Cancer Recurrence?
While not studied in every cancer type, over 20 observational
studies have examined the impact of physical activity on
cancer recurrence, cancer-related mortality, and overall
mortality. The research to date has been primarily limited to
survivors of breast, colorectal, prostate, and ovarian cancers.
These studies demonstrate that higher levels of postdiagnosis
physical activity are associated with a lower risk of disease
recurrence and improved survival. While this research has
demonstrated promise toward a direct effect of exercise
on the progression of cancer, further research is needed,
including randomized controlled trials. Nonetheless, physical
activity has a beneficial effect on preventing cardiovascular
disease, diabetes, and osteoporosis in the general population
that presumably would translate to cancer survivors.55,114
Therefore, cancer survivors should be encouraged to adopt a
physically active lifestyle.
Is Yoga Beneficial to Cancer Patients and Survivors?
Yoga has been studied in multiple intervention trials,
primarily testing its impact on health-related outcomes in
women with breast cancer. A recent meta-analysis demonstrated that yoga significantly improves psychological
health outcomes, including anxiety, depression, distress,
and stress.312 While yoga appears to have an impact on
psychosocial function, the benefits related to body
composition, fitness, and muscle strength are less evident.
A combination of yoga with aerobic exercise and resistance

training should be considered to maximize the benefit for
cancer survivors, although more research still needs to be
conducted.
Phytochemicals
What Are Phytochemicals, and Do They Reduce
Cancer Risk?
The term phytochemicals refers to a wide variety of
biologically active compounds in plants. Some have either
antioxidant or hormone-like actions both in plants and in
individuals who eat them.47 Studies examining the effects
of phytochemicals or selected plant foods such as vegetables
or fruits on cancer recurrence or progression are very
limited, and the little evidence that exists is inconsistent or
comes from only a few studies. There is no evidence that
phytochemicals taken as dietary supplements are as beneficial as the vegetables, fruits, beans, and grains from which
they are extracted.
Soy Products
Is Including Soy-Based Foods in the Diet Recommended
for Cancer Survivors?
Soy and soy-derived foods are an excellent source of protein
and, for this reason, a good alternative to meat. Soy contains
several phytochemicals, some of which have weak estrogenic
activity and seem to protect against hormone-dependent
cancers in animal studies. Other compounds in soy foods
have antioxidant properties and may have anticancer activities. There is considerable public and scientific interest in
the role of soy foods in the prevention of cancer in general
and breast cancer in particular, although scientific support
for such a role is inconsistent.313-316
For the breast cancer survivor, current evidence suggests
no adverse effects on recurrence or survival from consuming
soy and soy foods, and there is the potential for these foods
to exert a positive synergistic effect with tamoxifen.208
Sugar
Does Sugar Feed Cancer?
No. Sugar intake has not been shown to directly increase
the risk or progression of cancer. However, sugars (including honey, raw sugar, brown sugar, high-fructose corn
syrup, and molasses) and beverages that are major sources
of these sugars (such as soft drinks and fruit-flavored beverages) add substantial amounts of calories to the diet and
thus can promote weight gain, which adversely affects
cancer outcomes. In addition, most foods and beverages
that are high in added sugar do not contribute many
nutrients to the diet and often replace more nutritious food
choices. Therefore, limiting the consumption of foods and
beverages with added sugar is recommended.
265
Supplements
Would Survivors Benefit From Using Vitamin and
Mineral Supplements?
Survivors are strongly encouraged to obtain their needed
nutrients through foods, as opposed to supplements. While
dietary supplements are indicated in cases of nutrient
deficiency (either that which is confirmed through laboratory testing or through the clinical presence of disease
[eg, osteoporosis or osteopenia]), given the growing
literature on the adverse effects of nutritional intake beyond
normal levels,161,317 a concern exists that supplements may
do more harm than good.
Can Dietary Supplements Lower Cancer Incidence
or the Risk of Recurrence?
There is no evidence at this time that dietary supplements
can reduce the risk of recurrence or improve the likelihood
of survival.
Vegetables and Fruits

Will Eating Vegetables and Fruits Lower the Risk
of Cancer Recurrence?
A greater consumption of vegetables and fruits has been
associated in the majority of epidemiologic studies with a
lower risk of lung, oral, esophageal, stomach, and colon
cancers.47,318 Few studies exist, however, on whether a
diet high in vegetables and fruits can reduce the risk of
cancer recurrence or improve survival, although some
recent studies suggest increasing the intake of vegetables
may exert a beneficial effect on recurrence or survival for
breast, prostate, and ovarian cancers.140,141 Nonetheless,
consistent with the 2010 Dietary Guidelines for Americans,46
cancer survivors should be encouraged to consume at least
2 to 3 cups of vegetables and 1.5 to 2 cups of fruits each
day because of their health benefits. Because it is not
known which of the many compounds in vegetables and
fruits may be the most protective, the best advice is to
consume plenty of a variety of colorful vegetables and
fruits each day.
Is There a Difference in the Nutritional Value of Fresh,
Frozen, and Canned Vegetables and Fruits?
Yes, but they can all be good choices depending on availability,
economics, and ability to prepare food. Fresh foods are usually considered to have the most nutritional value. Often,
however, frozen foods can be more nutritious than fresh
foods because they are often picked ripe and quickly frozen;
nutrients can be lost in the time between the harvest and
consumption for fresh foods. Canning is more likely to
reduce the heat-sensitive and water-soluble nutrients because
of the high heat temperatures necessary in the canning
process.319 Be aware that some fruits are packed in heavy
266
syrup, and some canned vegetables are high in sodium. Choose

vegetables and fruits in a variety of forms. Frozen and canned
food may cost less to consume at certain times of the year.
Does Cooking Affect the Nutritional Value of Vegetables?
Cooking vegetables and fruits, especially with methods
such as microwaving or steaming in preference to boiling in
large amounts of water, preserves the bioavailability of
water-soluble nutrients and can improve the absorption of
others. For example, the carotenoids are better absorbed
from cooked vegetables than from raw vegetables.
Should I Be Juicing My Vegetables and Fruits?
Juicing can add variety to the diet and can be a good way to
consume vegetables and fruits, especially for those individuals who have difficulty chewing or swallowing. Juicing also
improves the bodys absorption of some of the nutrients in
vegetables and fruits. However, juices may be less filling
than whole vegetables and fruits and contain less fiber.
Fruit juice, in particular, can contribute excess calories to
ones diet if large amounts are consumed. Commercially
juiced products should be 100% vegetable or fruit juices and
should be pasteurized to eliminate harmful microorganisms.
This is true for the general population, but is of particular
concern for those who may be immunocompromised, such
as cancer patients undergoing chemotherapy.
Vegetarian Diets
Do Vegetarian Diets Reduce the Risk of Cancer
Recurrence?
No studies have demonstrated that consuming a vegetarian
diet has any additional benefit for the prevention of cancer
recurrence over an omnivorous diet high in vegetables,
fruits, and whole grains and low in red meats. However,
vegetarian diets can have many healthful characteristics
because they tend to be low in saturated fat and high in
fiber, vitamins, and phytochemicals320 and are consistent
with the ACS guidelines on nutrition and physical activity
for the prevention of cancer.
Water and Other Fluids

How Much Water and Other Fluids Should I Drink?
Many symptoms of fatigue, lightheadedness, xerostomia, bad
taste in the mouth, and nausea can be due to dehydration;
survivors should therefore be encouraged to try to remain
adequately hydrated. This is particularly important if they
are experiencing unexpected losses through vomiting and
diarrhea. Assuming no contraindications, a daily water intake
of 3.7 liters for men and 2.7 liters for women meets the
needs of most adults.321 Notably, about 80% of that water
is typically obtained from foods. If achieving adequate
hydration is difficult, survivors should speak to their medical
doctor regarding intravenous hydration.
American Cancer Society 2011 Nutrition,

Physical Activity and Cancer Survivorship
Advisory Committee
Volunteer Members: Rachel Ballard-Barbash, MD, MPH
(Associate Director, Applied Research Program, Division
of Cancer Control and Population Sciences, National
Cancer Institute, Rockville, MD); Elisa V. Bandera, MD,
PhD (Associate Professor, Department of Epidemiology,
The Cancer Institute of New Jersey, New Brunswick, NJ);
Tim Byers, MD, MPH (Associate Dean for Public Health
Practice, Colorado School of Public Health, Associate
Director for Cancer Prevention and Control, University of
Colorado Cancer Center, Aurora, CO); Kerry S. Courneya,
PhD (Professor and Canada Research Chair in Physical
Activity and Cancer, University of Alberta, Edmonton,
Alberta, Canada); Wendy Demark-Wahnefried, PhD, RD
(Professor and Webb Endowed Chair of Nutrition
Sciences, University of Alabama at Birmingham, Birmingham, AL); Barbara Grant, MS, RD, CSO, CD, (Oncology
Nutritionist, Saint Alphonsus Regional Medical Center
Cancer Care Center, Boise, ID); Kathryn K. Hamilton,
MA, RD, CSO, CDN (Outpatient Oncology Dietitian,
Carol G. Simon Cancer Center, Morristown Memorial
Hospital, Morristown, NJ); Laurence N. Kolonel, MD,
PhD (Deputy Director, Cancer Research Center of
Hawaii, Honolulu, HI); Lawrence H. Kushi, ScD (Associate Director for Etiology and Prevention Research,
Division of Research, Kaiser Permanente, Oakland, CA);
Marilyn L. Kwan, PhD (Research Scientist, Division of
Research, Kaiser Permanente, Oakland, CA); Mara Elena
References
Martnez, PhD (Associate Professor of Public Health,

Arizona Cancer Center, Tucson, AZ); Jeffrey Meyerhardt,
MD, MPH (Associate Professor of Medicine, Dana-Farber
Cancer Institute and Harvard Medical School, both in Boston, MA); Marion Morra (President, Morra Communications, Milford, CT); Marian L. Neuhouser, PhD (Cancer
Prevention, Fred Hutchinson Cancer Research Center,
Seattle, WA); Cheryl L. Rock, PhD, RD (Professor,
Department of Family and Preventive Medicine, School of
Medicine, University of California, San Diego, LaJolla,
CA); Anna L. Schwartz, FNP, PhD, FAAN (Affiliate Professor, University of Washington, Seattle, WA; Associate
Professor, Idaho State University, Pocatello, ID); and
Stephanie Smith-Warner, PhD (Associate Professor of
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CA CANCER J CLIN 2012;62:242-274

Nutrition and Physical Activity Guidelines

2012 American Cancer Society, Inc. doi:10.3322/caac.21142. Available online at cacancerjournal.com

Nutrition and Physical Activity Guidelines for Cancer Survivors

After receiving a diagnosis of cancer, survivors soon find

Overview of the Report

CA: A Cancer Journal for Clinicians

appropriate medical and supportive care and are seeking

Nutrition and Physical Activity Across the

Nutrition During Cancer Treatment and Recovery

CA CANCER J CLIN 2012;62:242-274

TABLE 1. Suggestions for Locating Specialized Nutrition Counseling

prevalence of malnutrition and weight loss varies widely

support may be needed, such as pharmacotherapy using

Exercise During Cancer Treatment

Nutrition and Physical Activity Guidelines for Cancer Survivors

is not only safe and feasible during cancer treatment, but

Recovery Immediately After Treatment

CA: A Cancer Journal for Clinicians

TABLE 2. American Cancer Society Guidelines on Nutrition and

neuropathy, changed sense of taste, difficulty chewing and

Long-Term Disease-Free Living or Stable Disease

CA CANCER J CLIN 2012;62:242-274

those with aerodigestive tumors such as head and neck,

Living With Advanced Cancer

Nutrition67 and the Academy of Nutrition and Dietetics

Selected Issues in Nutrition and Physical

Nutrition and Physical Activity Guidelines for Cancer Survivors

outcomes are possible, and likely probable, through

CA: A Cancer Journal for Clinicians

who need to lose weight, even if ideal weight is not

Physical Activity in Cancer Survivors

CA CANCER J CLIN 2012;62:242-274

TABLE 3. Adult BMI Chart

BMI indicates body mass index.

mortality and/or overall mortality, with improvements of up

women assigned to moderate intensity resistance and impact

Nutrition and Physical Activity Guidelines for Cancer Survivors

disease and diabetes have not been studied in cancer survivors,

CA: A Cancer Journal for Clinicians

guidelines is likely to provide additional health benefits.

Supporting Exercise Behavior Change

Dietary and Food Choices

CA CANCER J CLIN 2012;62:242-274

TABLE 4. Examples of Moderate and Vigorous Activities118

Ballroom and line dancing

VIGOROUS ACTIVITIES (I CAN ONLY SAY A FEW WORDS WITHOUT STOPPING

For example, a dietary pattern high in fruits, vegetables,

Inverse associations have been found between fat intake

Nutrition and Physical Activity Guidelines for Cancer Survivors

A few observational follow-up studies of diet and survival

CA: A Cancer Journal for Clinicians

effects such as lignans; and compounds that may influence

CA CANCER J CLIN 2012;62:242-274